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MENTAL  DISEASES 


MENTAL  DISEASES 


A     HANDBOOK     DEALING    WITH 
DIAGNOSIS  AND  CLASSIFICATION 


BY 

\¥ALTER  VOSE  GULICK,  M.D. 

ASSISTANT    SUPERINTENDENT    WESTERN    STATE    HOSPITAL, 
FORT    STEILACOOM,    WASHINGTON 


ILLUSTRATED 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1918 


Copyright,   191S,  By  C.  V.  Mosby  Company 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


DEDICATED  TO 

mi.  WILLIAM  NOBLE  KELLER 

A  TOKEN  OF  ESTEEM 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/mentaldiseaseshaOOguli 


PREFACE 

Recent  readjustment  in  certain  mental  groupings 
and  their  nomenclature  gives  a  special  interest  to 
those  terms  which  are  coming  into  common  use. 

The  short  chapters  put  under  this  cover  under- 
take a  statement  as  to  the  data  essential  in  the  rec- 
ognition of  the  different  psychoses. 

The  forms  of  mental  disease  mentioned  follow 
modern  usage.  The  first  chapter  gives  the  classifi- 
cation now  accepted  for  use  in  the  War  Department, 
and  recommended  for  general  adoption  throughout 
the  United  States. 

However,  the  order  of  presentation  belongs  to 
the  author,  and  is  intended  to  put  first  those  dis- 
orders that  are  most  frequent,  allowing  the  other 
divisions  to  be  placed  in  suitable  chapters. 

In  this  writing,  aside  from  the  direct  observation 
of  hospital  patients,  I  have  studied  the  subject  as 
given  in  various  texts,  particularly  those  of  Kraep- 
elin,  Dercum,  Tanzi,  Diefendorf,  White,  and  Jel- 
liffe. 

In  access  to  hospital  material,  criticism,  and  val- 
uable suggestions,  I  have  been  very  generously 
helped  and  here  wish  to  thank  those  to  whom  I  am 

7 


O  PREFACE 

indebted,  particularly  Dr.  W.  N.  Keller,  Dr.  Frank 
T.  Wilt,  Dr.  A.  C.  Stewart,  and  Dr.  Walter  T. 
Williamson. 

W.  V.  G. 

Fort  Steilacoom,  Wash. 


INTRODUCTION 

This  little  book  is  no  superfluity;  born  of  the 
wants  we  all  have  for  concise,  digested  information, 
it  institutes  a  response  to  that  need.  Dr.  Gulick 
felt  the  demand  as  others  have,  but  he  happily  re- 
sponded. The  physician  in  court,  or  conducting 
office  or  public  examinations  of  the  insane,  or  un- 
expectedly called  upon  for  diagnosis  in  private 
practice,  will  accept  this  book  with  relief.  It  is 
original  and  pleasing,  not  a  mere  compilation,  and 
has  much  pure  Anglo-Saxon  directness  and  clear- 
ness.    It  should  be  welcome  to  the  profession. 

W.  T.  Williamson,  M.D. 

Portland,  Oregon. 


CONTENTS 

CHAPTER  I 

PAGE 

Classification 17 

CHAPTER  II 
Definitions 22 

CHAPTER  III 
Examination 25 

CHAPTER  IV 
Manic  Depressive  Psychoses 30 

CHAPTER  V 
Dementia  Precox 40 

CHAPTER  VI 
GeneraIj  Paralysis 57 

CHAPTER  VII 
Paranoia 66 

CHAPTER  VIII 
Epileptic  Psychoses 74 

CHAPTER  IX 
Organic  DementIxV 79 

CHAPTER  X 

Involution  Psychoses 96 

11 


12  CONTENTS 

CHAPTER  XI 

PAGE 

Constitutional  iNFEraorJTY  and  Defective  Mental  Develop- 
ment  105 

CHAPTER  XII 
Intoxication  Psychoses Ill 

CHAPTER  XIII 
Thyroigenous  Psychoses 121 

CHAPTER  XIV 
Infection  and  Exhaustion  Psychoses 125 

CHAPTER  XV 
Psychogenic  Neurosis 130 

CHAPTER  XVI 

Constitutional   Psychopathic    States:     Undiagnosed   Psy- 
choses:    Incidental  Comments 134 

CHAPTER  XVII 
Shell  Shock 137 


ILLUSTRATIONS 

FIG.  PAGE 

1.  Manic  depressive  insanity,    manic   tyiie 33 

2.  Manic  depressive  psychosis^  manic  type 34 

3.  Manic  depressive  insanity 35 

4.  Manic  depressive  insanity,  depressed  type 37 

5.  Manic  depressive  insanity,  depressed  type 38 

6.  Dementia  precox,  hebephrenic  type 41 

7.  Dementia  precox,  hebephrenic  type 44 

8.  Dementia  precox,  hebephrenic  type 40 

9.  Letters  scratched  on  wall  by  a  dementia  precox     ....  47 

10.  Dementia  xjreeox,  katatouic  type 48 

11.  Dementia  precox,  katatonic  type 49 

12.  Dementia  precox,  paranoid  type 51 

13.  Dementia  precox,  paranoid  type 52 

14.  Dementia  xjrecox,  paranoid  type 53 

15.  Dementia  precox,  simple  type 55 

16.  General  paralysis,  advanced  second  stage 60 

17.  General  paralysis,  advanced  second  stage 62 

18.  Paranoia 68 

19.  Paranoia 69 

20.  Paranoia 70 

21.  Epileptic   insanity 77 

22.  Organic  dementia,  tabetic    psychosis 85 

23.  Organic  dem,entia,  cerebral   apoplexy 91 

24.  Organic  dementia,  cerebral  trauma 93 

25.  Organic  dementia,  cerebral  trauma 94 

26.  Involution  psychosis,   melancholia 97 

27.  Involution   i^sychosis,   melancholia 99 

28.  Involution  psychosis,  jiresenile   delusional   insanity     .     .     .  101 

29.  Involution  psychosis,  senile  dementia 103 

13 


14  ILLUSTRATIONS 

FIG.  PAGE 

30.  Constitutional   inferiority 106 

31.  Constitutional   inferiority 107 

32.  Defective  mental  development,  imbecility 108 

33.  Defective  mental  develoi)nient 109 

34.  Defective  mental  development 110 

35.  Intoxication  i)sychosis,  alcoholic  hallucinatory  dementia     .  117 

36.  Thyrogenous   psychosis,   cretinism 123 


MENTAL  DISEASES 


MENTAL  DISEASES 


CHAPTER  I 
CLASSIFICATION 

The  classification  of  mental  diseases  given  below 
is  the  one  adopted  by  the  American  Medico-Psycho- 
logical Association  in  May,  1917.  This  has  been 
recommended  for  general  adoption  throughout  the 
United  States,  and  has  been  accepted  for  use  in  the 
War  Department,  under  the  direction  of  the  Office 
of  the  Surgeon  General. 

PSYCHOSES 

1.  Traumatic  psychoses. 

2.  Senile  psychoses. 

3.  Psychoses  with  cerebral  arteriosclerosis. 

4.  General  paralysis. 

5..  Psychoses  with  cerebral  syphilis. 

6.  Psychoses  with  Huntington's  chorea. 

7.  Psychoses  with  brain  tumor. 

8.  Psychoses  with  other  brain   or  nervous   dis- 
eases (specify  when  possible). 

9.  Alcoholic  psychosis. 

(a)  Pathologic  intoxication. 

17 


18  MENTAL   DISEASES 

(b)  Delirium  tremens. 

(c)  Acute  hallucinosis. 

(d)  Korsakow's  psychosis. 

(e)  Chronic  paranoid  type. 

(f)  Other  types,  acute  or  chronic. 

10.  Psychoses  due  to  drugs  and  other  exogenous 
toxins. 

(a)  Morphine,  cocaine,  bromides,  chloral, 

etc.,    alone    or    combined    (to    be 
specified). 

(b)  Metals,  as  lead,  arsenic,  etc.   (to  be 

specified). 

(c)  Cases  (to  be  specified). 

(d)  Other  exogenous  toxins  (to  be  speci- 

fied). 

11.  Psychoses  with  pellagra. 

12.  Psychoses  with  other  somatic  diseases  (spec- 
ify disease). 

13.  Manic  depressive  psychoses. 

(a)  Manic  type. 

(b)  Depressive  type. 

(c)  Stupor. 

(d)  Mixed  type. 

(e)  Circular  type. 

14.  Involution  melancholia. 

15.  Dementia  precox. 

(a)  Paranoid  type. 

(b)  Katatonic  type. 


CLASSIFICATION  19 

(c)  Hebephrenic  type. 

(d)  Simple  type. 

16.  Paranoia  and  paranoic  conditions. 

17.  Psychoses  with  mental  deficiency. 

18.  Psychoses  with  constitutional  psychopathic  in- 
feriority. 

19.  Epileptic  psychoses. 

20.  Undiagnosed  psychoses. 

IIsrEBRIETY 

Alcoholism. 

Drug  addiction  (specify  drug). 

MENTAL   DEFICIENCY 

Imbecile. 

Moron. 

Borderline  condition. 

CONSTITUTIONAL   PSYCHOPATHIC   STATES 

Criminalism. 

Emotional  instability. 

Inadequate  personality. 

Nomadism. 

Paranoid  personality. 

Pathologic  liar. 

Sexual  psychopathy. 

Other  forms  (specify). 

Undiagnosed. 

This  classification  is  from  a  memorandum  of  the 


20  MEHSTTAL   DISEASES 

War  Department  that  accompanied  a  letter  sent  by 
the  office  of  the  Surgeon  General  to  the  Superintend- 
ent of  the  Western  State  Hospital  of  Washington, 
under  date  of  May  25,  1918,  and  is  a  part  of  the  in- 
structions given  under  direction  of  the  Surgeon  Gen- 
eral to  divisional  psychiatrists  and  other  medical 
officers  in  charge  of  neurological  and  psychiatric  ex- 
aminations. 

For  many  years  the  reading,  and  even  discussion, 
of  nervous  and  mental  diseases  has  been  dif&cult, 
and  inclined  to  apparent  confusion  of  thought,  be- 
cause of  lack  of  uniformity  in  the  meaning  of  words 
used.  These  difficulties  have  been  emphasized  by 
the  period  of  development  which  has  secured  a 
standing  for  the  manic  depressive  psychoses;  has 
expanded  the  dementia  precox  group;  limited  the 
cases  to  be  counted  as  true  paranoia;  and  come  to  a 
more  discriminating  appreciation  of  various  other 
forms. 

Further,  the  writers  on  these  subjects  have  been  in- 
dividualists, with  opinions  of  their  own  concerning 
classification.  The  result  has  often  been  shown  in 
court  room  disputes  which  concerned  a  definition 
more  than  a  condition.  All  who  read  these  subjects 
had  to  make  adjustments  between  authors,  and 
proper  statistics  have  been  impossible. 

The  country  is  now  indebted  to  the  American 
Medico-Psvchological  Association  for  shaping  the 


CLASSIFICATION  21 

present  table,  and  this  year  cooperating  with  the  Na- 
tional Committee  for  Mental  Hygiene,  to  secure  its 
introduction  throughout  the  country  and  it  is  in 
place  to  add  that  the  majority  of  the  state  hospitals 
have  already  either  adopted  this  new  system  or  indi- 
cated their  intention  to  do  so. 


CHAPTER  II 

DEFINITIONS 

Insanity  has  no  clean-cut  and  commonly  accepted 
definition.  This  word  goes  back  to  a  time  when  it 
was  believed  that  sickness  of  the  mind  was  all  of 
one  sort.  Now  there  is  a  recognized  group  of  sepa- 
rately defined  mental  diseases,  and  in  Appleton's 
Medical  Dictionary  insanity  is  frankly  called  an 
"obsolete  medical  term."  The  word  "psychosis," 
used  in  the  plural,  is  acceptable  and  suggests  fairly 
well  the  present  attitude  of  this  department  of  medi- 
cine which  may  regard  certain  mental  conditions, 
paresis,  dementia  precox,  paranoia  and  others,  as  in 
need  of  hospital  care,  just  as  general  medicine  may 
send  to  a  hospital  of  another  sort  cases  of  typhoid 
fever,  pneumonia  or  smallpox. 

The  psychiatrist  has  no  definition  for  his  o^^ai  use. 
Dercum  provides  for  the  court  room  the  explanation 
of  insanity  as  a  "diseased  state  in  which  there  is 
more  or  less  persistent  departure  from  the  normal 
manner  of  thinking,  acting  and  feeling,"  and  Dr. 
W.  A.  White  in  a  recent  address  has  spoken  of  in- 
sanity as  "a  certain  type  of  socially  inefficient  con- 

22 


DEFINITIONS  23 

duct,  a  certain  degree  of  socially  inefficient  conduct 
that  causes  trouble  in  the  community." 

In  law,  procedures  in  connection  with  insanity 
have  usually  to  do  with  the  question  as  to  whether 
an  individual  is  in  condition  to  properly  care  for 
himself  and  his  property.  Here  also  the  word  'in- 
sanity" is  loose  in  definition,  and  is  further  con- 
fused because  of  a  lack  of  uniformity  between  dif- 
ferent states. 

The  ground  for  commitment  is  found  when  there 
is  a  mental  departure  from  the  normal  self  of  the 
individual  of  such  duration  and  degree  as  to  dis- 
qualify him,  either  on  his  own  account  or  on  account 
of  others,  from  being  a  member  of  society. 

Common  Symptoms  of  Diagnostic  Value 

Ataxia  indicates  a  lack  of  muscular  coordination. 
Delusion  is  a  false  belief  which  can  not  be  cor- 
rected by  adequate  evidence. 

Hallucination  is  a  conscious  sensation  that  comes 
without  any  external  object  to  cause  it.  Thus  the 
act  of  hearing  when  there  is  nothing  to  hear,  or  of 
seeing  what  does  not  exist  (and  is  not  even  suggested 
by  any  object  in  sight)  is  a  hallucination.  Such  an 
impression  may  come  through  any  of  the  senses,  but 
hallucinations  of  sight  and  hearing  are  most  fre- 
quent. 


24  MEXTAL    DISEASES 

Illusion  is  a  wrong  interpretation  of  something 
that  really  exists. 

Orientation  expresses  the  conscions  relation  of  the 
individual  to  his  environment  and  may  concern  it- 
self with  place,  time,  and  people. 

Pressure  of  activity  indicates  a  mental  state  that 
demands  expression  in  extraordinary  muscle  activ- 
ity and  the  dominant  impulse  is  to  movement  on 
movement. 

Psycliomotor  activity  is  the  j)hrase  describing 
muscle  action  under  normal  nervous  control.  When 
there  is  undue  slo^^^less,  psycliomotor  retardation 
is  a  proper  term,  while  the  opposite  condition  is  de- 
scribed as  increased  psycliomotor  activity. 

Psychosis  is  a  mental  disease. 


CHAPTER  III 

EXAMINATION 

The  working  out  of  a  mental  diagnosis  may  take 
much  time  and  repeated  observations,  but  with  such 
an  opportunity  as  is  open  to  the  physician  when 
called  to  the  home  or  the  court  room,  usually  he  can 
reach  some  opinion  as  to  the  mental  condition  of 
the  patient,  so  as  to  give  advice  as  to  the  immedi- 
ate care  needed  and  to  comment  as  to  the  cause 
and  outcome. 

Under  such  circumstances  many  processes  of  the 
laboratory  or  of  a  full  clinical  examination  are 
either  out  of  reach  or  for  the  time  inexpedient,  but 
because  of  the  presence  of  friends  and  relatives  it 
is  ordinarily  possible  to  get  the  advantage  of  a  good 
history  and  this  may  mean  much. 

At  the  court  house  it  is  the  custom  to  follow  the 
procedure  of  the  commitment  blank,  while  in  the 
home  the  method  must  adapt  itself  so  as  to  consider 
the  patient  and  his  family. 

An  examination  routine  will  lessen  the  risk  of 
missing  points  that  count.  This  is  helped  by  a 
written  memorandum,  and  especially  in  cases  where 

25 


26  MENTAL   DISEASES 

some  legal  opinion  is  asked  a  record  of  statements 
in  the  words  of  the  patient  may  develop  value. 

There  are  four  general  heads:  (1)  History  of  the 
family,  (2)  personal  history  of  the  patient,  (3)  his- 
tory of  the  disease,  and  (4)  the  present  mental  and 
physical  condition  of  the  patient. 

1.  General  questions  seldom  get  a  family  history. 
It  is  well  to  begin  with  the  name,  occupation  and 
birthplace  of  the  father  and  mother  and  the  fact 
as  to  relationship  between  them;  also  to  know  the 
number  of  brothers  and  sisters,  and  then  in  re- 
gard to  each  of  these,  or  any  other  near  relative, 
to  learn  as  to  general  health,  deformities,  nervous 
diseases,  eiDilepsy,  asylum  commitment,  mental  pe- 
culiarity, known  bad  habits,  use  of  alcohol,  history 
of  suicide  or  prison  sentence. 

2.  The  personal  history  may  begin  by  asking  as 
to  incidents  that  marked  the  birth  of  the  patient, 
having  to  do  either  with  the  mother  or  the  child. 
Facts  as  to  general  health,  diseases,  injuries,  and 
operations  belonging  to  childhood  or  later  life  are 
to  be  recorded  as  well  as  information  secured  from 
such  questions  as  were  indicated  in  connection  with 
the  family  history.  Further,  there  is  to  be  noted 
the  years  at  school,  the  progress  of  the  child  as 
compared  with  others,  then  the  developments  that 
came  later  in  his  life  at  home  and  at  work.  In 
this  connection,  ability  for  physical    and    mental 


EXAMINATION  27 

work,  character  development,  habits  in  eating, 
forms  of  amusement,  or  the  use  of  narcotics  may- 
be of  significance.  Proi3er  inquiry  should  be  made 
as  to  emotional  disturbance,  which  is  particularly- 
liable  to  be  evident  at  puberty  and  in  connection 
with  the  menstrual  periods. 

3.  In  getting  the  history  of  the  disease,  a  direct 
question  may  bring  out  the  date  of  its  beginning, 
but  often  this  is  unknown,  for  not  infrequently  the 
disease  develops  slowly  and  goes  a  long  time  with- 
out recognition.  On  this  account,  the  date  given 
may  be  wrong,  indicating  only  the  time  when  cer- 
tain symptoms  forced  attention.  Sometimes  the  pa- 
tient can  give  for  himself  the  most  exact  and  accu- 
rate statement,  but  more  often  the  story  is  best 
secured  from  his  family. 

It  is  important  to  know  whether  there  have  been 
previous  attacks,  and  if  so  Avhether  or  not  the  in- 
terval seemed  to  give  a  normal  condition. 

The  story  of  the  onset  and  the  subsequent  symp- 
toms is  sometimes  told  in  a  connected  way,  but  more 
often  it  has  to  be  asked  for  in  a  series  of  questions 
that  may  need  to  be  repeated  for  different  periods. 
For  this  the  ground  is  well  covered  by  the  outline 
used  by  Diefendorf  both  here  and  in  recording  the 
mental  status  of  the  patient.  This  notes  information 
as  to  hallucinations,  illusions  and  delusions,  and  also 
as  to  disturbances  in  orientation,  attention,  memory 


ZQ  MENTAL    DISEASES 

and  train  of  thought,  as  well  as  in  the  emotional  and 
volitional  fields. 

4.  In  judging  the  present  condition  of  the  patient 
the  physical  examination,  aside  from  the  general 
findings  of  the  chest  and  abdomen,  should  note  the 
manner,  attitude,  degree  of  nourishment  and  any 
stigmata  of  degeneration,  or  evidence  of  cyanosis; 
also,  the  different  reflexes,  particularly  the  pupil- 
lary, should  be  observed. 

Information  as  to  the  mental  state  has  been  se- 
cured through  the  several  stages  of  the  examination, 
but  is  properly  reviewed  as  to  disturbance  under 
the  headings  mentioned. 

Perception  (hallucinations  or  illusions.) 

Apprehension  (unconscious,  befogged  or  dimin- 
ished sensibility). 

Attention  (blunted,  blocked,  retarded,  passive  or 
easily  distracted). 

Memory  (impressibility  faulty,  retentiveness 
faulty,  fabrication). 

Orientation  (does  the  patient  know  where  he  is 
and  who  he  is). 

Train  of  thought  (paralysis  of,  retardation,  com- 
pulsive, persistent  ideas,  flight  of  ideas,  desultori- 
ness). 

Judgment  (Are  there  delusions?). 

Emotional  field  (deterioration,  irritability,  seclu- 
siveness,  fear,  dejection,  feeling  of  well  being,  sexual 
manif  e  stations ) . 


EXAMINATION  29 

Volitional  fidd  (paralysis,  retardation,  hyporsug- 
gestibility,  cerea  flexibility,  stereotypy,  negativism, 
pressure  of  activity,  mannerisms). 

In  this  way  data  can  be  obtained  for  a  provisional 
diagnosis,  though  there  will  at  times  be  occasion  for 
later  revision. 

Before  ending  this  chapter  mention  is  properly 
made  of  psychoanalysis,  which  is  a  procedure  by 
which  search  is  made  for  the  elemental  thoughts  or 
incidents  that  lie  at  the  beginning  of  the  mental  dis- 
turbance. This  method  properly  carried  out  holds 
large  possibilities,  but  in  its  nature  and  the  time  re- 
quired, goes  beyond  the  limits  of  the  type  of  exam- 
ination to  which  these  pages  belong. 


CHAPTER  IV 

MANIC  DEPEESSIVE  PSYCHOSES 

Manic  depressive  insanity  includes  cases  that  used 
to  be  divided  among  different  groups  and  named 
mania,  melancholia,  or  circular  insanity. 

Credit  is  given  to  Kraepelin  for  showing  the  en- 
tity of  this  psj^chosis.  In  mania  and  melancholia 
alike  the  patient  continued  free  from  progressive 
mental  deterioration.  Each  ran  through  a  period 
of  mental  disturbance  followed  by  a  relatively  free 
interval  with  a  later  recurrence..  It  was  observed 
that  in  mania,  depression  might  precede  the  state  of 
excitement  or  follow  as  an  interval  shadow;  while 
in  melancholia  the  patient  at  times  showed  a  varia- 
tion marked  by  some  tendency  towards  excitement, 
and  often  this  change  of  type  was  definite. 

Thus  came  the  recognition  of  manic  depressive 
insanity,  which  has  a  manic  type,  a  depressed  type, 
and  a  mixed  type,  and  this  mixed  form,  when  alter- 
nation is  direct  mthout  any  interval,  is  called  cir- 
cular insanity. 

There  are  no  characteristic  pathologic  changes. 
The  influence  of  heredity  is  not  infrequently  made 

30 


MANIC   DEPRESSIVE   PSYCHOSES  31 

plain  by  the  family  history.  A  constitutional  pre- 
disposition seems  to  yield  before  some  circumstance 
of  strain.  It  is  not  unusual  to  have  the  disease  be- 
gin without  any  apparent  cause.  However,  in  these 
instances  a  full  anamnesis  may  bring  out  both  the 
hereditary  taint  and  the  nature  of  the  circumstance 
that  fixed  the  date  of  development. 

The  manic  type  is  divided  into  hypomania,  acute 
mania  and  hyperacute  mania.  These  forms  place 
the  degree  of  development.  There  are  three  impor- 
tant symptoms:  flight  of  ideas,  psychomotor  excite- 
ment and  emotional  excitement.  The  ideas  that  come 
are  normal  in  character,  but  each  in  turn  tends  to 
fail  of  being  rounded  out,  because  it  is  too  quickly 
crowded  aside  by  the  next,  which  is  soon  lost  in  the 
one  that  follows.  In  the  phrase  '^flight  of  ideas" 
we  have  a  figure  that  suggests  thoughts  coming  in 
such  a  flock  as  to  interfere  with  each  other.  Thus 
ideas  come  too  close  together  to  find  space  in  time 
to  unfold. 

But  in  hypomania  this  is  not  necessarily  a  marked 
symptom.  Emotional  excitement  usually  attracts 
attention  and  the  patient  may  be  nervous  and  quick, 
perhaps  superficially  clever.  There  is  increased  ac- 
tivity, which  is  inclined  to  change  its  direction  and 
thus  fail  of  any  reasonable  result.  The  individual 
act  will  be  normal  enough  in  character  but  liable  to 
be  broken  off  anywhere,  and  often  there  is  uncalled 


32  MENTAL    DISEASES 

for  irritability.  As  these  incidents  are  prominently 
placed  the  work  of  the  man  is  broken  and  his  usual 
life  made  impossible. 

Acute  mania  emphasizes  this  picture,  the  flight 
of  ideas  attracts  attention;  an  attempt  at  conversa- 
tion shows  a  medley  of  sentences  and  phrases,  but 
between  these  there  is  usually  connection, — that  is, 
the  one  idea  in  some  way  calls  the  next;  it  may  be 
similarity  of  sound  or  previous  association,  or  a  re- 
mote connection  of  any  sort,  that  carries  the  patient 
rapidly  on  without  apparent  exhaustion.  A  flight 
of  ideas  stops  ordinary  observation,  and  in  conse- 
quence the  patient  seems  disoriented,  to  lack  mem- 
ory and  ability  of  apprehension,  all  to  an  extent 
that  is  beyond  the  fact.  He  can  not  keep  still,  and 
every  impulse  leads  to  action  which  now  easily  goes 
to  violence.  A  manifestation  of  excitement  is  often 
the  most  striking  s^^nptom,  but  this  by  itself  is  not 
enough  to  put  the  patient  definitely  in  this  group 
because  dementia  precox,  general  paresis,  epileptic 
insanity,  senile  dementia  and  certain  other  psychoses 
may  show  periods  of  similar  excitement,  where  the 
differential  diagnosis  requires  other  symptoms  as 
well  as  the  physical  signs,  which  in  certain  cases 
are  of  most  importance. 

Hallucinations  and  delusions  can  come,  but  are 
neither  essential  nor  permanent.  Occasionally  there 
is  a  grotesque  decoration  of  the  person.    Flight  of 


MANIC   DEPRESSIVE   PSYCHOSES 


33 


Fig.   1. — Manic  depressive  insanity,  manic  type. 


34  MEIs^TAL   DISEASES 

ideas,  psychomotor  excitement  and  emotional  ex- 
citement go  on  rather  evenly.  These  three  symp- 
toms increase  for  a  certain  period,  which  may  be  a 


Fig.  2. — Manic   depressive  psychosis,   manic   type,   but   here   showing  depressed 

state. 


week  or  more,  reach  a  climax  and  then,  gradually 
lessening,  indicate  the  progress  of  a  convalescence 
from  this  particular  attack  that  may  stretch  tedi- 
ously through  several  months.    The  pulse  is  usually 


MANIC   DEPRESSIVE   PSYCHOSES 


35 


Fig.   3. — Manic    depressive    insanity,    manic    type.      Ilair    over    face,    hands    in 
violent  motion. 


36  MENTAL   DISEASES 

fast,  pulse  pressure  low,  knee  jerks  exaggerated, 
and  the  pupils  equal. 

The  hyperacute  stage  finds  the  patient  exhausted 
from  violence,  incoherent,  delusional,  with  conscious- 
ness clouded,  and  an  emaciation  complicated  with 
toxemia. 

The  depressed  type  also  has  three  open  symptoms : 
difficulty  of  thinking,  psychomotor  retardation,  and 
emotional  depression.  The  beginning  often  is 
marked  by  some  situation  that  causes  worry.  Thus 
a  painter  and  paper-hanger,  subnormal  in  health 
from  exposure  to  lead,  when  out  of  work  for  several 
months,  brooded  over  the  matter  and  could  not 
sleep,  had  a  poor  appetite,  sat  around,  attempted 
some  work  but  could  not  carry  it  through.  He  left 
work  undone  without  knowing  why,  hung  paper 
upside  down,  and  in  other  ways  proved  himself  in- 
competent and  was  often  unreasonable.  This  man 
was  recently  committed,  but  from  this  sequence  we 
do  not  hold  the  lack  of  work  as  an  adequate  cause 
for  what  followed,  though  it  was  the  incident  of 
precipitation. 

Such  a  patient  will  often  sit  relaxed  and  apathetic, 
with  folded  hands  and  head  bowed.  It  is  hard  for 
him  to  think  and  difficult  to  act.  He  lacks  energy 
to  begin,  moves  with  hesitation,  and  if  started  can 
not  finish  anything.  A  man  sent  to  help  in  caring 
for  guinea  pigs  was  weighed  down  by  the  thought 


MANIC   DEPRESSIVE   PSYCHOSES 


37 


Fig.  4. — Manic  depressive  insanity,  depressed  type. 


MENTAL   DISEASES 


Fig.  S. — Manic  depressive  insanity,  depressed  type. 


MANIC    DEPIIESSIVE    PSYCHOSES  39 

of  his  responsibility.  The  degree  of  depression  may 
be  painful.  Speech  is  an  effort  and  the  words  are 
sometimes  so  indistinct  that  the  sentence  is  easily 
lost.  But  patience  in  listening  may  prove  the  ability 
of  the  patient  to  remember  and  think  correctly. 
Often  there  are  feelings  of  self-condemnation,  and 
delusions  may  go  in  this  direction.  The  most  fre- 
quent hallucination  is  that  of  smell,  which  is  liable 
to  be  of  some  disagreeable  sort. 

Physically  the  discomforts,  as  dizziness,  palpita- 
tion, tinnitus  and  heavy  limbs  can  be  largely  ex- 
plained through  a  faulty  circulation.  The  weight 
may  be  subnormal,  the  blood  pressure  increased, 
and  the  pulse  slow.  Simple  retardation,  acute  melan- 
cholia, and  stuperous  melancholia  are  divisions  that 
indicate  the  degree  of  depression,  the  last  of  which 
is  a  befogged  condition  with  the  patient  unable  to 
respond  to  the  processes  of  an  examination. 

The  diagnosis  of  the  manic  tj^pe  from  dementia 
precox,  and  of  the  depressed  type  from  senile  melan- 
cholia may  take  time.  Here  the  essential  informa- 
tion sometimes  is  obtained  from  a  history  that  tells 
of  relatively  long  lucid  intervals,  with  different  re- 
current attacks.  This  recurrence  is  characteristic 
of  this  disease;  and  with  the  diagnosis  once  made 
the  prognosis  expects  another  attack,  though  there 
may  be  an  indefinite  interval  even  of  months  reach- 
ing into  years. 


CHAPTER  V 

DEMENTIA  PRECOX 

Dementia  precox  is  perhaps  the  mental  disorder 
that  takes  more  young  people  to  institutional  care 
than  any  other.    In  Washington  this  gave  over  one- 
third  of  the  total  admittance  for  the  last  biennium. 
,   It  is  a  condition  of  mental  deterioration.     The  cor- 

I  tical  cells  show  some  degeneration  and .  the  neu- 
roglia may  be  increased,  but  the  pathologic  find- 

_i^  ings  are  limited.    The  cause  of  this  disease  has  not 
been  established,  but  a  rather  generally  accepted 
theory  is  that  of  an  endogenous  toxic  effect,  got  pos- , 
sibly  by  the  functional  disturbance  of  a  sex  gland. 

..  However,  some  of  the  best  recent  work  tends  to 
find  a  psychogenic  beginning,  with  a  loss  of  balance 
in  the  mental  metabolism. 

There  are  three  main  groups :  the  hebephrenic,  the 
katatonic,  and  the  paranoid,  which  have  in  com- 
mon certain  fundamental  markings.  Where  conver- 
sation is  possible  the  examination  usually  develops 
a  mental  isolation  that  is  characteristic,  and  makes 
the  somewhat  hidden  background  for  other  tj^Dical 
manifestations,  as  negativism  and  indifference.     A 

40 


DEMENTIA   PRECOX 


41 


muscular  tension  frequently  emphasizes  the  nega- 
tivism, while  the  apparent  indifference  may  show 
both  in  attitude  and  speech.  The  clinical  picture 
has  been  called  polymorphous,  but  these  features, 


Fig.   6. — Dementia  precox,  hebephrenic  type. 

mental  isolation,  negativism  and  indifference,  are 
usually  in  some  degree  evident. 

Further,  the  orientation  is  persistently  good;  the 
patient  knows  who  he  is  and  where  he  is,  though 
the  examiner  may  be  led  astray  as  to  his  observa- 


42 


MENTAL   DISEASES 


tion  in  a  field  that  is  controlled  by  some  other  symp- 
tom; and  at  the  time  of  commitment  it  is  rather 
usual  for  some  degree  of  either  excitement  or  stupor 
to  be  in  evidence. 

From  beginning  to  end  the  symptoms  are  such  as 
may  be  developed  through  a  mental  deterioration, 
and  it  is  this  fact  well  held  in  mind  that  secures  a 
fair  understanding  of  the  entity  that  gives  to  care- 
ful examination  a  group  which  allows  more  possi- 
bilities for  individual  variation  than  any  other  form 
of  mental  disease,  and  sometimes  puts  close  together 
in  diagnosis  patients  that  show  contrast  in  manner, 
speech  and  history. 

The  intellect  and  the  emotions  have  lost  com- 
panionship; in  consequence  cause  and  effect  may 
seem  to  have  queer ly  gone  wrong ;  the  expression  of 
pleasure  may  be  clearly  out  of  place;  a  silly  laugh 
may  go  on  as  an  uncontrolled  physical  performance. 
A  broken  pane  of  glass,  or  the  loss  of  home  and 
property  are  mentioned  evenly  with  implied  indif- 
ference. 

And  this  indifference  which  often  is  apparent  is 
perhaps  not  so  much  a  real  indifference  as  it  is  a 
lack  of  observation,  a  perception  which  is  too  in- 
sufficient to  either  prompt  action  or  thought.  The 
beginning  may  be  slow,  characterized  by  indefinite 
or  even  misleading  evidence.  The  child  in  some  in- 
stances is  precocious,  but  in  time  the  tendency  to 


DEMENTIA   PRECOX  43 

suioeriiciality  grows ;  cleverness  proves  a  veneer  only, 
and  mental  deterioration  in  some  degree  is  under- 
neath, though  in  school,  social  life  or  business,  this 
may  for  a  while  be  well  covered. 

The  beginning  is  usually  slow  and  even  when  the 
progress  from  the  first  open  symptom  leads  to  com- 
mitment quicker  than  is  usual,  in  the  light  of  what 
has  happened  there  can  be  found  suggestive  color 
in  the  earlier  history  of  the  patient. 

Once  developed,  the  disease  often  shows  itself  in 
mannerisms  and  repetitions  of  speech  or  action,  and 
there  may  be  an  apparent  looseness  of  thought  for 
which  psychoanalysis,  where  possible,  can  uncover 
the  connection.  Rarely  an  epileptiform  convulsion 
occurs. 

1.  Of  the  three  definite  types,  the  hebephrenic  is 
the  most  frequent  form  and  its  beginning  is  usually 
unrecognized.  The  dementia  may  show  first  sim- 
ply lack  of  ability  to  think  and  do  well  what  might 
be  normally  expected,  from  this  going  on  with  a  self- 
centered  attitude  to  a  marked  carelessness  in  con- 
duct. Such  a  patient  may  brood  or  be  irritable,  be- 
come restless  and  irresponsible,  develop  some  or  all 
of  the  symptoms  that  have  been  mentioned  as  com- 
monly characteristic  of  this  disease.  Sexual  passion 
may  display  itself.  Hallucinations  are  liable  to  be 
of  a  disagreeable  variety,  and  are  most  often  of 
hearing,  though  bad  smells  and  disturbing  sights 


44 


MEI^TAL   DISEASES 


are  what  the  senses  sometimes  find.  Delusions  which 
are  often  of  persecution,  but  may  go  in  other  direc- 
tions, are  likely  to  be  indefinite  and  shifting;  and 
especially  is  it  suggestive  to  have  the  patient  give  at 


Fig.   7. — Dementia  precox,   hebephrenic   tj-pe. 

random  outlandish  or  inadequate  reasons  as  ex- 
planation of  the  delusions  or  for  his  conduct,  and  to 
be  entirely  satisfied. 


DEMENTIA   PRECOX  45 

An  Italian  writer  has  used  the  expression  ^ '  stolid- 
ity of  conduct,"  but  for  the  hebephrenic  type  a 
dullness  of  emotion,  with  an  irresponsible  indiffer- 
ence, seems  a  closer  comment  in  many  cases. 

Physically  the  changes  are  such  as  might  be  ex- 
pected with  a  condition  made  subnormal  in  certain 
ways  by  the  mental  life.  A  low  blood  pressure  is 
usual. 

A  year  ago  a  young  man  just  of  age,  who  had  been 
firing  on  a  small  steamship,  was  judged  insane. 
His  commitment  papers  state  that  during  the  pre- 
ceding twelve  months  his  actions  and  disposition 
changed  radically,  he  refused  to  eat  with  others, 
used  his  hands  only,  became  a  glutton,  had  dirty 
habits,  threatened  people,  swore,  went  for  months 
without  a  bath  and  claimed  that  all  kinds  of  perse- 
cution were  being  practiced  against  him.  A  report 
from  the  grandmother  tells  that  the  father  was  a 
drunkard.  The  patient  as  a  little  boy  was  likeable 
and  bright  in  his  studies,  but  this  did  not  last; 
later  he  became  impudent  and  lazy  and  neglectful 
of  his  appearance,  the  change  being  particularly  evi- 
dent when  he  was  about  fourteen. 

With  other  findings  the  hospital  examination  ob- 
served the  patient  as  stupid  and  confused,  noted  a 
diminished  sensibility  to  external  stimuli,  clouding 
of  consciousness,  retardation  of  attention,  desultory 
train  of  thought,  psychomotor  retardation,  and  al- 


46 


MEXTAL   DISEASES 


I"ig.    S. — Dementia   precox,    hebephrenic    tj'pe. 


DEMENTIA   PRECOX  47 

ready  knowing  the  history  made  a  diagnosis  of  the 
hebephrenic  form  of  dementia  precox. 

Under  hospital  care,  this  young  man  improved 
physically  and  mentally,  and  within  several  months 
l)ecame  an  agreeable  patient  and  good  worker,  de- 
livering supplies  from  the  commissary. 

On  March  21  of  this  year  he  was  paroled  into  the 
care  of  his  grandmother,  but  was  returned  in  August 
as  he  became  impudent,  threatening  and  disagreea- 
ble in  his  habits. 


Fig.    9. — These   letters   were   scratched   on  the   wall   by   a   dementia   precox   who 
did  the  same  thing   (with   a  nail)    in  a  number  of  rooms. 

2.  Katatonia  often  displays  very  openly  as  its 
main  symptom  a  stiffness  of  attitude  supported  by 
negativism  and  stupor.  Some  of  these  patients  go 
to  extreme  length  in  resistance  to  everything  and 
in  maintenance  of  postures.  The  condition  of  stupor 
may  change  to  one  of  excitement  or,  after  lasting 
months,  may  in  a  short  time  make  a  marked  improve- 
ment. 

Ten  months  ago  an  Austrian,  twenty-two  years 
old,  was  admitted.    He  was  in  bed  and  would  hold 


48 


MENTAL   DISEASES 


Fig.  10. — Dementia  precox,  katatonic  type. 


DEMENTIA   PRECOX 


49 


Fig.   11. — Dementia  precox,   katatonic   type. 


50  MENTAL    DISEASES 

indefinitely  the  positions  into  which  he  was  put,  un- 
til lost  through  fatigue.  He  could  be  stood  or  moved 
as  an  automaton,  and  continued  for  months  in  this 
condition.  Now  he  is  up,  able  to  walk,  stands  much 
of  the  time,  is  occasionally  angry  and  then  may  bite, 
scratch  or  strike.  Recently  he  put  his  hand  through 
a  window.  Much  of  the  time  he  stands  in  a  charac- 
teristic katatonic  attitude,  but  will  now  eat  if  left 
alone  with  food. 

3.  The  paranoid  type  gives  prominence  to  more  or 
less  fixed  and  progressive  delusions,  often  of  per- 
secution, together  with  other  findings  that  show  the 
patient  a  precox  case. 

A  delusion  founded  on  some  hallucination  is  fre- 
quent enough  to  be  characteristic,  but  the  connec- 
tion may  be  vague.  A  young  man  hears  voices  talk- 
ing, not  to  him,  but  so  that  he  can  overhear  in  part. 
He  believes  that  the  voices  belong  to  some  girl  ac- 
quaintances, who  are  at  the  time  on  the  roof  and 
are  calling  on  him  to  help  because  they  are  there 
being  abused. 

For  some  the  dementing  process  comes  quickly, 
and  then  the  delusions  more  easily  go  to  absurdities 
and  grotesque  fancies.  A  musician,  in  his  thirties, 
fills  his  conversation  with  a  medley  of  delusions.  He 
tells  the  story  of  a  fight  between  two  musicians  as 
to  whether  violins  or  banjos  are  being  used  in  China, 
and  in  close  connection  adds  that  the  priesthood  or- 


DEMENTIA    PRECOX 


51 


ganizes  on  overcoats  and  sells  overcoats.  He  states 
that  the  Bass  Clef  Society  and  the  Weenie,  Weenie 
Walker  Club  use  different  colors;  that  hymn  1098 


Fig.    12.- — Dementia  precox,   paranoid   type. 


was  written  in  that  year;  that  the  color  in  his  eye 
reveals  to  him  that  he  sees  snakes  and  has  been  fed 


52 


MENTAL   DISEASES 


Fig.   13. — Dementia  precox,  paranoid  type. 


DEMENTIA   PRECOX 


53 


on  snake  eggs.    He  talks  with  Jim  Hill  indirectly 
and  Mr.  Hill  pays  musicians  to  study  the  Bible. 

More  commonly  the  mental  deterioration  is  slowly 
progressive,  and  the  accompanying  delusions  occa- 


Fig.  14. — Dementia  precox,  paranoid  type.  This  patient  claims  to  be  Presi- 
dent of  the  United  States,  Mayor  of  Seattle  and  Mayor  of  Tacoma,  and  wishes 
to  be  released  so  as  to  accept  his  official  responsibilities. 


sionally  persist  through  months  with  little  or  no 
change. 

Thus  a  young  man  committed  by  the  Seattle  court 


54  MEXTAL   DISEASES 

three  years  ago  has  continued  his  delusions  of  per- 
secution. His  good  physical  condition  and  his 
straightforward,  earnest  manner  easily  hold  atten- 
tion. He  believes  that  he  is  illegally  held  and  wishes 
to  have  this  matter  at  once  brought  before  the  proper 
court,  but  with  a  chance  to  speak  to  the  physician 
or  anyone  else,  goes  on  to  tell  with  detail  how  he 
is  burned  each  night  by  electricity  that  comes  from 
some  machine  outside  the  building.  For  some 
weeks  he  kept  a  diary  which  he  wishes  for  court 
evidence,  and  this  on  each  -page  tells  of  the  burning 
by  electricity. 

Between  this  t^^^De  of  a  delusion  and  those  of 
paranoia  there  is  similarity,  but  there  is  also  an  es- 
sential difference  which  is  best  measured  in  the  ex- 
tent of  stability  that  belongs  to  the  one  above  the 
other.  The  delusion  of  a  paranoiac  holds  with  the 
firmness  of  an  oak  that  grips  solidly  into  the  right 
ground  with  its  root;  while  the  delusion  of  the 
paranoid  dementia  precox  is  more  like  the  California 
Yucca,  which  one  easily  uproots  from  its  sandy  soil. 
The  dementia  is  the  soil  that  prevents  the  same 
degree  of  fixity  and  systematization  that  charac- 
terize the  delusions  of  paranoia. 

In  addition  to  the  three  main  types  discussed  a 
simple  type  is  now  recognized  in  diagnosis.  This 
form  is  related  to  the  hebephrenic,  but  the  marks  of 
dementia  are  not  as  distinctive.     The  beginning  is 


DEMENTIA    PRECOX 


00 


Fig.   15. — Dementia  precox,  simple  type.     Was  a  tramp,  pockets  were  filled  with 

rubbish. 


56  MENTAL   DISEASES 

of  a  gradual  sort.  Definite  delusions  and  disagreea- 
ble hallucinations  may  work  a  period  and  then  fade. 
Even  simple  responsibilities  are  not  decently  car- 
ried. Many  prostitutes  and  tramps  have  belonged 
in  this  group.  Recently  men  of  this  sort  have  passed 
through  various  recruiting  offices  into  the  army, 
where  their  conduct  has  usually  got  them  into  the 
guard  house,  from  which  they  have  been  properly 
removed  to  institutional  care  or  returned  to  their 
homes. 

No  age  line  can  be  strictly  placed,  but  it  has  been 
observed  that  cases  in  the  hebephrenic  group  usu- 
ally begin  when  between  fourteen  and  twenty  years 
old,  those  of  the  katatonic  t^^De  in  the  third  decade, 
and  of  the  paranoid  sort  when  over  thirty. 

In  dementia  precox  many  cases  reach  some  degree 
of  improvement,  but  relatively  few  recover  so  as 
to  stay  apparently  normal.  For  the  paranoid  type 
the  prognosis  as  to  recovery  is  bad. 


CHAPTER  VI 

GENERAL  PARALYSIS 
(Paresis;  General  Paresis;  Dementia  Paralytica) 

In  an  institution  general  paralysis  is  a  rather  well 
defined  group,  carried  by  organic  changes  in  the 
brain  through  a  characteristic  course  marked  by 
progressive  mental  and  physical  deterioration, 
which  in  its  last  stage  usually  holds  the  patient  bed- 
fast to  a  uniform  end. 

For  each  of  the  several  synonyms  in  the  above 
heading  there  is  good  authority.  General  paralysis 
has  the  approval  of  present  army  usage.  In  the 
name  dementia  paralytica  the  words  themselves  are 
properly  descriptive.  Paresis  is  a  shorter  term  that 
may  come  into  general  use,  while  general  paresis 
is  more  accurate.  General  paralysis  of  the  insane 
was  the  phrase  with  which  Kraepelin  first  named 
the  disease,  and  by  some  it  is  still  preferred. 

Outside,  the  beginning  comes  without  recognition; 
the  date  of  the  first  symptoms  is  found  later  by  ret- 
rospection. But  an  early  diagnosis  is  of  much  con- 
sequence and  may  go  far  to  save  a  family  gross  em- 

57 


58  MEXTAL   DISEASES 

barrassment,  and  to  hold  the  patient  from  business 
indiscretions  of  a  serious  sort. 

The  pathologic  findings  for  this  disease  are  rich 
in  detail,  and  taken  as  a  group  give  a  definite  diag- 
nosis. The  skull  is  often  unevenly  thickened,  T^^ith 
the  dura  stuck  fast  in  spots,  while  an  effort  to  move 
the  joia  tears  at  points  into  the  brain  substance. 
The  whole  brain  is  somewhat  shrunken,  with  fluid 
in  the  free  spaces  and  evidence  of  inflammation 
going  below  the  surface.  Xerve  fibers  and  cells 
show  degenerative  distortion;  this  is  also  true  of 
blood  vessels  and  hTuphatics.  There  is  an  increase 
in  caiDillaries  and  often  there  are  irregular  dilata- 
tions and  perivascular  deposits.  Lesions  of  an  in- 
flammatory type  mark  the  spinal  cord,  and  there 
may  be  areas  of  softening. 

The  cause  of  general  paresis  is  now  accepted  as 
sj7)hilis,  but  the  nature  of  the  incident  that  brings 
this  disease  of  the  posttertiary  stage  to  one  and  pro- 
tects ninety-nine  others  is  unknown. 

The  first  evidence  often  comes  as  a  character 
change.  A  man  of  respected  standing  may  develop 
irregular  habits  that  go  any  length  in  the  disregard 
shown  for  custom  or  the  ethics  of  society.  Ability 
for  api^lication  is  lost;  indifference  to  detail  is  fol- 
lowed by  an  irresponsibility  which  can  be  partly 
hidden  even  while  it  is  emphasized  by  an  overac- 
tivity in  attending  to  matters  at  hand.    Emphasis 


GENERAL    PARALYSIS  59 

will  often  be  put  in  the  wrong  place.  A  tendency 
to  overlook  important  detail  makes  work  unreliable ; 
carelessness  usually  shows  in  dress.  All  fine  ma- 
nipulations are  difficult,  and  the  fingers  grow  awk- 
ward at  knotting  a  tie.  Lapses  of  memory  go  on  to 
defects  which  may  be  repaired  by  the  imagination; 
whatever  enters  the  mind  may  come  to  be  stated  as 
a  fact.  Easily  the  patient  lets  go  of  money,  grow- 
ing disinclined  to  work,  and  often  for  an  outlandish 
act  he  gives  an  outlandish  reason,  with  an  apparent 
belief  in  its  sufficiency.  There  is  an  expressed  con- 
fidence as  to  immediate  ability  for  doing  large  things. 
A  man  without  money  thus  comes  to  talk  of  using 
millions  in  railroad  construction,  possibly  to  the 
moon. 

Delusions,  while  not  essential  to  the  picture,  are 
usual,  and  when  they  come  change  easily  and  tend 
to  absurdities,  particularly  as  to  wealth  and  power. 

Variation  from  a  normal  pupil  can  usually  be 
found  at  some  period  in  the  disease,  but  is  not  al- 
ways permanent.  The  Argyll  Eobertson  reaction, 
or  either  an  inequality  or  rigidity  of  the  pupils  is 
significant,  and  the  consensual  reflex  may  be  lost. 
The  knee  jerks  are  most  frequently  normal  or  ex- 
aggerated, but  may  be  lost. 

Further  development  is  marked  by  the  paretic 
seizure  and,  while  this  does  not  always  come,  it  is 
especially  a  characteristic  incident.     Epileptiform 


60 


MENTAL   DISEASES 


Fig.  16. — General  paralysis,   advanced   second  stage. 


GENERAL   PARALYSIS  61 

and  apoplectiform  are  used  as  descriptive  adjec- 
tives. This  convulsion  is  at  times  indistinguishable 
from  that  of  true  epilepsy  and  can  have  as  many 
variations,  but  is  inclined  to  last  longer  and  to  clear 
less  completely.  Thus  after  every  such  attack  the 
degree  of  dementia  is  deepened  and,  though  after- 
wards improvement  comes  slowly,  each  time  it  fails 
to  quite  get  back  what  was  lost.  Such  a  seizure, 
where  there  is  no  family  history  of  mental  disease, 
is  suggestive. 

While  there  may  have  been  earlier  intervals  when 
the  symptoms  could  have  been  easily  overlooked, 
the  changes  that  follow  take  a  more  definite  course. 

Already  a  loss  of  muscle  tone  has  lessened  facial 
expression,  smoothed  away  wrinkles  and  caused  the 
nostrils  to  spread.  And  also  there  has  been  some 
speech  disturbance;  a  monotonous  tone  carries  the 
words  with  lost  accent,  and  the  difficulty  in  articu- 
lation is  brought  out  by  test  words  as  ' '  Seattle  Post- 
Intelligencer.  ' ' 

All  these  symptoms,  as  well  as  the  other  findings 
already  named,  grow  more  apparent.  Speech,  but 
writing  more,  loses  syllables  and  leaves  out  words. 
The  signature  is  sprawling  and  the  address  loses 
letters  and  becomes  illegible.  The  Eomberg  sign 
is  usual  and  the  gait  ataxic. 

Finally  the  patient  is  put  to  bed  because  with 
growing  weakness  the  unsteady  gait  has  made  it 


62 


MENTAL   DISEASES 


Fig.   17. — General   paralysis,  advanced  second  stage. 


GENERAL    PAnALVRTS  63 

unsafe  for  him  to  walk.  Then  he  lies  bedridden  for 
weeks  or  months,  often  unable  to  do  anything  for 
himself;  only  constant  care  may  protect  him  from 
bed  sores.  Almost  always  there  is  appetite  and  good 
ability  to  eat.  A  feeling  of  well-being  continues  sel- 
dom broken,  mental  deterioration  increases,  conver- 
sation becomes  impossible,  but  an  occasional  word 
suggests  former  delusions. 

It  is  rather  customary  to  name  three  stages.  The 
first  develops  the  prodromal  symptoms  and  proves 
the  incapacity  of  the  individual  who  has  feelings 
of  special  well-being.  The  second  begins  with  the 
seizure,  emphasizes  all  the  previous  abnormalities 
and  adds  physical  changes.  The  third  has  the  pa- 
tient in  bed.  This  disease  has  many  variations:  a 
convulsion  may  mark  its  introduction;  the  patient 
is  sometimes  in  a  condition  to  attract  much  atten- 
tion, but  the  course  may  go  to  its  end  without  any 
happening  of  consequence. 

As  to  subgroups  there  are  no  clean-cut  divisions. 
A  demented  type  called  typical  goes  from  a  gradual 
onset  through  a  routine  course.  The  expansive  type 
attracts  attention  with  extravagantly  ridiculous  de- 
lusions. The  agitated  form  shows  excitement,  has 
extreme  delusions,  and  runs  a  short  course;  while 
the  depressed  form  often  shows  a  clouded  conscious- 
ness with  delusions  of  self -accusation. 

The  prognosis  gives  a  three-year  average,  but  the 


64  MENTAL   DISEASES 

expansive  type  may  have  periods  of  relative  re- 
covery and  live  two,  three  or  four  times  as  long. 

In  diagnosis  it  is  well  to  have  in  mind  the  fact 
that  an  epilejDtiform  convulsion  for  a  man  in  mid- 
dle life,  without  a  history  of  epilepsy,  is  suggestive. 

As  already  said,  early  recognition  is  often  very 
important.  Impaired  judgment,  a  change  of  dispo- 
sition, moral  obtuseness  and  self-satisfying,  inade- 
quate explanations  are  grounds  sufficient  for  sus- 
picion. 

Spinal  fluid  examination  may  be  a  valuable  aid, 
when  it  can  get  as  confirmatory  evidence  a  positive 
Wassermann,  Nonne's  albumin  test,  Lange's  gold 
chloride  test,  and  a  cell  count  of  over  20.  And  these 
findings  will  at  times  be  positive,  while  the  Wasser- 
mann for  the  blood  stays  negative. 

The  differentiation  from  an  alcoholic  psychosis  is 
made  when  the  alcohol  is  withheld.  The  other  con- 
dition which  may  simulate  the  prodromal  stage,  is 
hysteria,  but  here  the  attitude  of  the  paretic  to- 
wards himself  is  essentially  different  for  he  never 
overstates  personal  discomforts,  but  later  develops 
physical  signs. 

In  September  1914  a  German  mechanical  engineer, 
thirty-two  years  old,  was  received  here.  Ten  years 
before  he  had  been  treated  for  syphilis.  During  the 
year  before  commitment  he  came  gradually  from 
an  energetic,   cheerful  disposition  to  be  irritable. 


GENERAL    rArwM.VSiS  65 

He  had  a  desire  to  have  and  spend  money,  l)ut  no 
inclination  to  earn  it.  He  became  indolent,  indif- 
ferent and  imaginative.  His  wife  wrote,  "He  spent 
foolishly  all  we  had,  yet  thinks  we  are  wealthy." 
At  the  time  of  examination  he  said,  "I  also  invented 
that  electric  aeroplane,  that  big  cast-iron  one;  you 
remember  the  time  I  went  up  in  Seattle.  It  is  made 
of  three-inch  armor  i^late.  I  just  invented  it  for 
commercial  use.  When  I  left,  my  wife  asked  for 
$15,000,  but  I  gave  her  $500,000.  I  bought  a  lot  of 
silk  for  seven  dollars,  but  when  I  got  home  and 
opened  the  box  there  was  $15,000  worth  of  silk." 

The  Wassermann  examinations  for  serum  and 
spinal  fluid  were  positive,  Nonne  jDositive  and 
Lange's  positive,  the  cell  count  130  to  the  cubic 
millimeter. 

There  have  been  some  variations  in  the  condition 
of  this  patient.  Treated  by  the  Byrnes  method  he 
had  twenty-four  intradural  injections  of  mercury,  as 
w^ell  as  intramuscular  injections.  On  the  whole  the 
change  has  been  one  of  increasing  weakness  and  men- 
tal deterioration.  In  this  period  he  has  taken  food 
with  relish  and  been  free  from  evidence  of  suffering. 
He  died  after  being-  bedfast  for  several  months. 


CHAPTER  VII 

PARANOIA 

Paranoia  names  a  form  of  insanity  which,  though 
relatively  infrequent,  is  known  to  the  public  through 
the  newspapers  because  of  different  trials  that  have 
attracted  general  attention,  with  a  defendant  so 
mentally  alert  that  in  court  it  has  been  hard  to  show 
convincing  reason  for  committing  or  holding  him  in 
restraint. 

In  paranoia  the  life  of  an  individual  is  marked 
with  a  system  of  delusions  slowly  developing  from 
a  series  of  false  conceptions.  The  delusion  is  not 
the  disease,  but  it  is  the  one  characteristic  and  es- 
sential feature  of  this  psychosis. 

There  is  often  some  constitutional  defect,  with  a 
family  history  in  the  background,  while  the  recog- 
nized beginning  in  early  adult  life  may  be  con- 
nected with  some  circumstance  of  strain  or  special 
disturbance. 

The  general  conduct  ma}"  be  near  normal,  and  the 
mental  condition  go  without  evidence  of  fault  when 
conversation  does  not  touch  the  diagnostic  delu- 
sions. Pathologic  studies  are  negative  in  their 
findings. 

CG 


PARANOIA  G7 

When  the  diagnosis  is  made  it  may  be  possible 
to  go  back  through  ten  years  and  put  together  in- 
cidents that  belong  to  an  earlier  picture.  An  in- 
sidious and  gradual  development  is  the  rule.  Ir- 
ritable conduct  and  an  inclination  to  grumbling  may 
be  remembered,  brightness  or  flightiness  may  have 
been  remarked  and  also  a  tendency  to  suspicions 
that  had  a  trivial  cause  or  no  cause  at  all.  This  last 
is  an  early  characteristic  and  is  of  the  most  sig- 
nificance. The  individual  may  show  himself  sensi- 
tive, distrustful  and  inclined  to  hold  aloof  even  from 
friends.  Ideas  of  persecution  may  take  the  victim 
away  from  his  work  from  one  place  to  another,  gain- 
ing no  more  relief  than  a  temporary  respite,  for  the 
delusion  is  not  long  left  behind. 

The  man  who  is  at  first  suspicious  may  lead  him- 
self to  the  thought  of  definite  persecution,  from 
which  he  tries  to  go  away  but  finds  that  he  is  per- 
sistently followed,  and  so  in  the  end  turns  on  his 
tormentors.  This  sentence  is  perhaps  the  statement 
of  a  history  that  runs  through  some  years  and  ends 
with  the  development  of  a  dangerous  stage. 

When  false  interpretations  finally  give  prominence 
to  fixed  delusions  that  show  themselves  shaping 
into  a  system,  the  paranoiac  may  be  named  as  such. 
Other  psychoses  have  delusions  too,  and  in  paranoid 
dementia  precox  these  may  be  measurably  fixed,  but 
the  paranoiac  in  all  his  earlier  stages  stays  free  from 


68 


IVrEl^TAL   DISEASES 


Fig.   18. — Paranoia.     This  man  states  that  he  is  a  priest  democrat  and  a  social 
democrat.      Claims   that   fighting  is   his  business.     Delusions   fixed. 


PAIlANOrA 


G9 


Fig.  19. — Paranoia.     The  discoverer  of  radium.     Speaks  easily,  has  abrupt  self- 
confident   manner,    drops    eyelids    while   talking.      Has    cynical    expression. 


70 


MENTAL   DISEASES 


Fig.  20. — Paranoia. 


PARANOIA  71 

tlie  other  evidences  of  mental  deterioration  that  go 
with  dementia.  His  delusions  have  been  well  termed 
fixed,  systematized  and  progressive,  and  are  often 
neither  absurd  nor  impossible.  In  fact,  they  are 
often  so  plausible  that  the  unfamiliar  mind  can  not 
be  convinced  of  their  falsity  until  other  evidence 
appears. 

The  developed  paranoiac  is  rather  the  aristocrat 
of  the  asylum.  Touching  his  system  he  is  expected 
to  stay  impervious  to  reason.  But  at  times  this  may 
be  a  buried  fact  and  hard  to  get  at.  Often  his  as- 
sertions are  found  to  be  not  carefully  made,  and  this 
is  so  although  at  the  same  time  he  speaks  with  em- 
phasis and  an  extra  show  of  confidence.  Certain 
acts  the  patient  may  recognize  as  foolish,  but  for 
these  he  is  ready  to  elaborate  an  explanation. 

At  the  end  as  in  the  beginning,  the  patient  is 
found  with  a  system  of  connected  delusions  influ- 
encing his  life,  but  is  not  much  marked  by  any  other 
changes. 

The  delusion  of  persecution,  which  is  usually  fun- 
damental, ma}''  lead  into  others  as  love,  religion  or 
grandeur,  and  there  are  cases  of  this  sort  that  go 
on  to  develop  a  changed  personality  and  to  claim 
the  identity  of  some  distinguished  name. 

Alienists  quite  generally  agree  that  a  genuine  case 
of  paranoia  does  not  recover  and  is  dangerous  in 
his  liability  to  commit  violent  assault.    But  recently 


/  '1  ZMEXTAL   DISEASES 

attention  lias  been  called  more  to  tlie  interpretative 
attitude  wliicli  in  this  psycliosis  seeks  to  study  first 
the  events  in  the  patient's  life  that  gave  those  ma- 
terial incidents  from  which  the  delusions  were  made, 
and  then  to  know  their  manner  of  development  and 
the  extent  of  influence  acknowledged  in  the  life  of 
the  patient.  The  result  has  been  to  recognize  dif- 
ferent paranoid  forms  as  belonging  elsewhere  and 
also  to  slioAv  reason  for  being  somewhat  less  dog- 
matic in  denying  the  possibility  of  effectiveness  to 
every  therapeutic  measure.  And  the  prognosis  needs 
in  each  case  to  consider  the  individual,  particularly 
in  relation  to  the  history  of  his  delusions,  their  kind, 
degree  of  develoi^ment,  and  fixedness.  This  is  im- 
13ortant  for,  while  recovery  is  not  looked  for,  the 
immediate  need  of  full  supervision  can  thus  be 
judged.  As  a  class  the  paranoiacs  are  dangerous 
and  clever,  and  persuasive. 

This  cleverness  may  go  with  big  schemes.  Thus 
'Mt.  X.  three  years  ago  proved  his  ability  to  the  em- 
barrassment of  a  well  known  comjDany  in  getting 
from  them  the  acceptance  of  his  note  for  over  a 
million  dollars  for  ninety  days.  And  it  was  while 
selling  stock  under  the  plan  thus  arranged  that  he 
was  taken  into  court  and  committed  after  a  trial 
by  jury.  In  the  asylum  he  has  since  developed  a 
system  of  fixed  delusions  in  which  those  in  authority, 
particularly  the  judge  of  the  committing  court,  are 


PARANOIA 


I .) 


held  associated  with  a  conspiracy  to  restrain  him 
illegally.  In  this  connection  he  has  made  many  de- 
tailed written  statements,  addressed  to  newspapers, 
attorneys  and  different  prominent  men. 


Comparative  Table 


MANIC- 
DEPRESSIVE 
PSYCHOSES 

DEMENTIA 
PRECOX 

GENERAL 
PARALYSIS 

PARANOIA 

MENTAL 
DETERIORA- 
TION 

No    marked 
change. 

Yes. 

Yes. 

No. 

DEr.USIONS 

Transitory 

and 

reasonable. 

Usual.      Often 
of  persecution. 

Frequently    of 

ridiculous 

exaggerations. 

Systematized. 

HALLUCINA- 
TIONS 

Sometimes 
transitory. 

Frequent, 
especially 
hearing. 

Occasional. 

Rare. 

PSYCIIO-MOTOR 
ACTIVITY 

Retardation 
or    hyper- 
activity. 

Indifference. 
Negativism. 

Occasional    in- 
crease,    but 
usually     grad- 
ually    progres- 
sive   sluggish- 
ness. 

Usually 
normal. 

PRINCIPAL 

MENTAL 

SYMPTOMS 

Difficult 
thinking   or 
flight    of 
ideas. 

Isolation    of 
patient.      Out 
of  contact 
with    immedi- 
ate environ- 
ment. 

Fabrication    of 
memory. 

Normal      men- 
t  al  '  processes 
but     fault      in 
judgment. 

PHYSICAL 

SIGNS 

Incidental    to 
disease    stage. 

Circulatory 
disturbance. 
Katatonic 
type:    muscu- 
lar tension 
and  waxy 
flexibility. 

Pupillary     and 
speech  disturb- 
ance.         Knee 
jerks      vary; 
are    often    ex- 
aggerated. 

Negative. 

ORIENTATION 

Normal   or 
apathetic, 
rarely 
delusional 

Normal. 

Becomes 
disturbed. 

Normal. 

CHAPTER  VIII 

EPILEPTIC  PSYCHOSES 

Epileptic  feeble-mindedness  with  the  classical 
grand  mal  or  lighter  petit  mal  is  a  subject  belong- 
ing to  general  medicine,  but  in  the  study  of  legal 
and  mental  diseases  acquires  special  importance  for 
there  is  no  other  morbid  state  that  so  often  holds 
responsibility  for  unprovoked  criminal  action.  A 
social  deterioration  thus  may  shape  a  vagabond,  or 
explosive  violence  lead  to  arson,  murder  or  immoral 
offences.  The  variety  of  possibilities  is  hardly 
limited. 

The  qu-estion  of  insanity  msij  be  one  for  nice  ad- 
justment, for  the  diagnosis  must  take  well  into  ac- 
count the  history  of  the  case,  the  mental  and  phys- 
ical markings,  and  then  judge  as  to  whether  the  pro- 
tection of  others  or  the  welfare  of  the  patient  makes 
commitment  advisable. 

With  a  story  of  violence  that  may  be  repeated,  the 
need  can  not  be  set  aside  and  crimes  of  exposure 
may  settle  the  point,  but  there  are  other  cases  where 
the  resources  of  the  home  are  to  be  considered  as 
well  as  the  patient  himself. 


EPILEPTIC    PSYCHOSES  -    75 

Defective  heredity  is  frequent.  In  this  connec- 
tion parental  alcoholism  and  epilepsy  are  to  be  spe- 
cially mentioned,  though  many  other  physical  and 
mental  faults  are  put  in  the  same  list. 

The  pathology  varies  as  does  the  cause,  and  so  it 
is  better  to  put  the  word  in  the  plural  and  to  speak 
of  the  epilepsies.  The  true  epilepsy  which  has  an 
obscure  etiology  usually  is  marked  by  sclerotic 
changes  in  the  hippocampus  major  or  a  gliosis  near 
the  surface  of  the  hemispheres.  It  is  this  form,  with- 
out any  clear  etiology,  that  most  often  goes  on  to 
mental  manifestations. 

The  sjmiptom  best  known  in  epilepsy  is  the  con- 
vulsion, but  for  convulsions  there  are  different  causes 
which  at  times  can  name  a  disease,  and  each  of  these 
as  recognized  in  general  medicine  should  have  suffi- 
cient consideration.  But  it  is  a  period  of  uncon- 
sciousness in  connection  with  the  convulsion  that  is 
of  most  diagnostic  value.  This  may  be  very  short 
or  may  last  through  several  hours.  And  in  close 
connection  there  can  happen  a  preconvulsive  or  post- 
convulsive twilight  stage,  sometimes  stretching 
through  different  days.  And  it  is  just  at  this  time 
that  the  dangerous  acts  of  an  epileptic  are  likely  to 
occur.  Often  there  is  evident  confusion  with  fur- 
ther mental  disturbance  which  may  show  various 
forms  of  indiscretion,  and  violence  may  immediately 
precede  or  follow  the  convulsion.     But  further  it 


76  MENTAL   DISEASES 

must  be  held  in  mind  that  with  rather  obscure  evi- 
dence for  diagnosis  there  may  be  acts  of  a  criminal 
nature  for  which  the  disease  is  the  cause.  Also, 
instead  of  any  frank  convulsion,  there  may  be  an 
epileptic  equivalent,  perhaps  a  recurring  incident 
of  confusion  or  depression,  that  in  certain  cases  can 
prove  a  diagnosis  of  legal  importance. 

The  patient  often  shows  marks  of  degeneration,  as 
jug-handle  ears  or  other  malformations.  There  may 
be  significant  scars  on  the  tongue  or  larger  ones  on 
the  head.  A  clumsiness  may  go  with  the  progres- 
sive feeble-mindedness.  Some  are  quick-tempered  or 
surly,  with  an  easy  change  of  mood,  while  others 
may  be  dull  and  good-natured  with  a  hesitating, 
dragging  speech  that  attempts  a  painstaking  accu- 
rac}^  of  detail.  Hallucinations  are  rather  the  excep- 
tion, illusions  may  develop  near  the  attack,  and 
sometimes  there  are  delusions  of  an  extraordinary 
sort.  In  the  interval  the  orientation  is  usually  good 
and  the  conduct  normal. 

A  lumberman  thirty-seven  years  old,  admitted 
August  5,  1915,  was  five  years  in  prison  in  Finland 
for  shooting  his  father,  and  over  ten  jears  ago  was 
in  this  institution.  As  to  the  occasion  of  this  recent 
commitment  he  says,  "The}^  tell  me  that  I  got  into 
a  fight  with  another  fellow.  They  took  me  to  the 
hospital  and  then  bring  me  here.  I  have  had  those 
spells  since  I  was  a  boy.    I  don't  know  when  they 


E1>1  LEPTrC!    PSYOnOSKS 


77 


Fig    21-KpiIeptic    insanity.      Shows    marks    from    fall,    also    some    degree 
*=■        '  of  dementia. 


78  MENTAL   DISEASES 

are  coming  because  they  come  like  lightning.  It 
takes  me  in  the  brain  and  head  and  goes  in.  Some- 
times I  would  be  sitting  down.  Most  of  the  time  it 
begins  quick.  I  don't  see  anything  when  I  have 
those  spells.  I  had  trouble  with  a  woman,  and  when 
it  come  on  that  time  it  was  like  a  cloud  coming  into 
my  face  and  I  was  out  (unconscious)  about  nine 
hours. ' ' 

Epilepsy  is  a  disease  of  youth,  and  75  per  cent 
have  been  reported  as  beginning  before  the  twentieth 
year. 

The  jDrognosis  is  bad,  but  in  some  cases  the  in- 
tervals may  be  long.  And  in  the  degree  of  mental 
disturbance  between  patients  there  are  big  dif- 
ferences. 


CHAPTER  IX 

ORGANIC  DEMENTIA 

1.  Huntington's   Chorea. 

2.  Multiple   Sclerosis. 

3.  Cerebral  Syphilis. 

4.  Tabetic  Psychosis. 

5.  Arteriosclerotic    Psychosis. 

6.  Brain  Tumor. 

7.  Brain  Abscess. 

8.  Cerebral  Apoplexy. 

9.  Cerebral  Trauma. 

The  anatomic  basis  given  in  structural  change  is 
the  common  fact  that  brings  these  several  psychoses 
into  the  same  group. 

1.  Huntington's  Chorea. — Huntington's  chorea  is 
a  chronic  and  slowly  progressive  disease.  Usually 
the  beginning  comes  with  the  patient  over  thirty. 
There  is  no  connection  with  Sydenham's  chorea. 
The  etiology  is  not  kno^^ai,  but  the  hereditary  evi- 
dence is  emphatic;  generations  may  be  skipped,  but 
it  is  a  disorder  that  belongs  definitely  to  its  own 
families. 

Pathologic    changes    as    meningeal    thickening, 

79 


80  MEXTAL    DISEASES 

general  brain  atropliy  and  arteriosclerosis  may  cause 
the  mental  symptoms,  while  midbrain  degenerations 
can  explain  the  motor  signs. 

The  mental  and  physical  symptoms  may  or  may 
not  come  on  together  and  grow  evenly.  The  move- 
ments are  irregular,  incoordinated,  slower  than  in 
acute  chorea,  often  begin  in  the  hands  and  are  some- 
what under  voluntary  control.  Facial  muscles  may 
be  irregularly  moved  with  the  slow,  loose  jerks 
which  show  in  a  larger  way  in  the  muscle  groups  of 
the  extremities  and  may  involve  most  of  the  volun- 
tary muscles  of  the  whole  body.  Gait  is  swaying. 
In  the  end  walking  and  writing  become  impossible. 

The  early  mental  changes  have  to  do  with  a  weak- 
ness of  memory  and  judgment.  There  are  grades  of 
feeble-mindedness,  often  irresponsibility  in  work 
and  irritability  in  conduct.  These  symptoms  de- 
velojD  and  become  comiDlicated  with  the  physical  con- 
ditions. The  speech  may  be  made  explosive  or  in- 
distinct. Delusions  and  hallucinations  are  not  fre- 
quent, and  suicide  seldom  happens.  The  disease 
makes  an  uncontrolled  progress. 

2.  Multiple  Sclerosis. — Multiple  sclerosis  is  a  dis- 
ease with  scattered  sclerotic  areas,  pinhead  size  and 
larger,  found  irregularly  in  any  part  of  the  brain, 
cord,  medulla,  pons  or  cerebellum,  and  may  involve 
the  nuclei,  roots  or  trunks  of  the  cranial  nerves;  con- 
sequently there  is  a  striking  variety  of  s^Tnptoms. 


OR(!ANI(;   I)EI\rKXTrA  81 

The  condition  is  relatively  infrequent.  In  half  the 
cases  no  cause  is  found.  In  others  acute  infections, 
chronic  intoxications  and  heredity  are  named. 
Early  adult  life  is  usually  the  time  of  beginning. 

Motor  disturbances  are  far  more  prominent  than 
mental  symptoms.  JMuscular  weakness  is  the  rule 
and  this  comes  often  without  atrophy.  The  gait 
shows  stiffness  and  the  feet  drag  on  the  floor.  Mus- 
cle rigidity,  intention  tremor,  nystagmus,  scanning- 
speech,  the  easy  fatigue  of  speech  muscle,  paresis  of 
eye  muscles,  apoplectiform  seizures,  dull  pains, 
neuralgia,  dyspnea,  optic  neuritis,  and  ataxia  are 
among  the  i^ossible  symptoms,  but  any  of  these  ma}^ 
be  missing.  Knee  jerks  and  other  tendon  reflexes 
are  increased,  ankle  clonus  can  be  expected  and 
Babinski's  sign  is  frequent. 

Then  mental  disturbance  is  usuall}^  of  a  lesser  de- 
gree and  seldom  is  sufficient  to  take  the  patient  to 
a  hospital.  Hallucinations  Avith  mild  confusion,  dif- 
ficulty in  thinking  and  a  faulty  memory  are  evident, 
while  periods  of  excitement  or  depression  are  pos- 
sible. Laughing  and  crying  may  be  involuntary  and 
indicate  a  muscular  rather  than  an  emotional  fault. 
Apoplectiform  and  epileptiform  attacks  sometimes 
happen. 

The  form  of  the  symptom  group  depends  upon  the 
location  and  extent  of  the  sclerotic  patches.  A 
gradual  beginning  of  manifold  symptoms,  with  im- 


82  MEXTAL   DISEASES 

provements  and  relapses,  gives  ground  for  suspicion 
while  the  tj^ical  case  goes  on  through  a  slow,  un- 
even course  to  develop  intention  tremor,  s^Dastic 
paresis,  nystagmus,  scanning  speech,  ataxia,  in- 
creased reflexes,  optic  atrophy  and  apoplectic  mani- 
festations, along  with  some  limited  involvement  of 
the  mentality  and  sensation,  with  also  functional 
disturbances  of  the  bladder  and  rectum. 

The  prognosis  has  in  mind  a  course  marked  by 
remissions,  gradually  progressive,  running  six 
months  to  ten  years  or  longer. 

3.  Cerebral  Syphilis  (Vascular). — Syphilis  may 
invade  any  part  of  the  nervous  system.  The  loca- 
tion and  the  degree  of  development  control  the 
clinical  picture,  which  usually  has  a  name  of  its  own 
to  indicate  the  structures  that  are  diseased. 

AYithin  the  present  decade  laboratory  studies  have 
done  much  to  establish  sj^Dhilis  as  the  direct  and 
common  cause  of  certain  allied  disease  t^^Des,  pre- 
viously distinguished  by  their  clinical  findings. 
Thus  cerebral  s^iohilis  and  jDaresis  are  nearer  to- 
gether than  they  used  to  be.  Whether  the  one  may 
grow  into  the  other  is  a  question  that  has  been  an- 
swered both  ways.  The  groups  made  by  different 
authors  somewhat  vary. 

Jelliffe  and  White  in  1915  take  up  cerebral  syph- 
ilis as  vascular  and  parenchymatous  and  regard  this 
parenchymatous  form  as  paresis.    They  call  repeated 


OllGANIC    DEMENTIA  83 

attention  to  the  fact  that  syphilis  seklom  limits  it- 
self carefully  to  any  one  spot  or  tissue.  Conse- 
quently, it  is  probable  that  the  description  of  a 
pure  tj^pe  would  often  be  blurred  if  the  full  path- 
ologic changes  Avere  known.  In  this  fact  lies  one 
reason  for  the  great  variety  of  symptoms. 

In  the  vascular  form  a  period,  varying  from  a 
few  months  to  fort}?-  years,  may  come  between  the 
infection  and  the  recognition  of  cerebral  syphilis. 
Nearly  half  of  these  cases  develop  symptoms  within 
three  years.  Headache,  dizziness,  insomnia  and  ap- 
athy are  often  prodromal  incidents.  In  the  begin- 
ning usually  there  is  a  defective  memory  and  defec- 
tive judgment,  with  a  failure  to  recognize  these 
faults.  There  is  likely  to  be  an  overconfidence  in 
strength  and  abilitj^,  and  perhaps  at  the  same  time 
evident  weakness  of  will.  Periods  of  marked  irri- 
tability usually  come. 

Of  clinical  pictures  there  is  an  indefinite  number. 
Some  suggestive  combination  is  expected.  Among 
other  findings  the  following  may  occur:  Alterations 
of  the  pupil,  choked  disc,  optic  neuritis,  vomiting, 
dementia  cured  by  treatment,  monoplegias,  epilepsy, 
hemianesthesia,  nerve  disturbances,  abnormal  sleepi- 
ness, palsies,  despondency,  stupidit}^,  character 
change,  hallucinations,  delusions,  and  characteristic 
writing.  No  one  of  these  is  essential,  but  often  sev- 
eral are  in  association. 


84  MENTAT.    DISEASES 

The  great  value  of  the  laboratory  findings  is  now 
appreciated.  Usually  the  Wassermann  for  the  blood 
is  2^ositive.  For  the  spinal  fluid  the  Wassermann  is 
likewise  positive,  also  Nonne's  albumin  and  Lange's 
gold  chloride  color  tests;  while  the  cell  count,  called 
normal  at  ten,  is  called  abnormal  at  twent}'-  and  may 
go  to  one  hundred  or  more. 

In  cases  where  the  symptoms  are  close  to  those  of 
paresis,  the  findings  may  hold  the  diagnosis  of  cere- 
bral syphilis,  but  leave  it  a  matter  of  opinion  as  to 
whether  the  syphilitic  process  has  already  gone  from 
the  vascular  to  the  parenchymatous  type. 

As  stated  above,  sj^ahilis  in  the  nervous  system 
may  involve  any  tissue  within  reach,  be  it  brain  or 
spinal  cord  or  membranes,  and  the  selection  made 
is  responsible  for  the  clinical  disease  that  follows. 
With  the  common  cause  recognized,  the  explanation 
of  different  overlapping  pictures  is  helped.  For 
tabes  dorsalis  and  paresis  the  expression  "para- 
S}T3hilis"  has  been  used,  but  the  occasion  for  this 
extra  term  is  not  beyond  dispute,  if  these  really  are 
just  forms  of  disease  due  to  infection  within  the  lim- 
its of  cerebrospinal  syphilis.  The  present  classifica- 
tion is  in  the  process  of  adjustment  and  can  not  be 
regarded  as  fixed. 

4.  Tabetic  Psychosis. — Tabes  dorsalis  is  a  chronic 
poisoning  caused  b}^  syphilis.  The  examination  of 
the  blood  and  spinal  fluid  is  now  added  to  the  other 


ORGANIC   DEMENTIA 


85 


Fig.   22. — Organic   Jciiiculia,    laljctic   ptjcliuM? 


86  MENTAL    DISEASES 

established  clinical  findings  which  belong  to  general 
medicine. 

In  some  cases  there  is  mental  disturbance.  There 
may  be  forgetfulness,  a  showing  of  easy  fatigue,  as 
well  as  some  changes  in  disposition.  Sometimes 
there  is  a  more  abrupt  beginning  of  the  mental  s^Tiip- 
toms,  with  the  patient  excited  and  restless,  and  then 
hallucinations  of  hearing  are  often  prominent.  Such 
a  condition  can  clear  and  may  recur.  The  orienta- 
tion is  normal.  In  the  tabetic  psychosis  the  degree 
of  deterioration  is  not  progressive,  and  in  this  it 
is  different  from  paresis. 

5.  Arteriosclerotic  Psychosis. — Arteriosclerotic  in- 
sanity is  a  chronic  disease,  but  with  jDaroxysmal  clin- 
ical evidence,  with  s^miptoms  that  come  and  clear 
as  allowed  by  the  developments  that  have  followed 
the  changes  in  the  cerebral  arteries.  Syphilis  and 
alcohol  are  often  mentioned  as  being  responsible  for 
the  beginning. 

When  there  is  a  general  systemic  condition  the 
factors  usually  prominent  are  chronic  toxemia,  hy- 
pertrophy of  the  left  ventricle,  high  blood  pressure, 
and  a  chronic  nephritis.  In  such  a  case  some  atro- 
phy of  the  whole  brain  is  expected,  and  thickening 
of  the  arterial  walls. 

But  the  disease  does  not  necessarily  mean  a  gen- 
eral arteriosclerosis,  for  the  condition  may  be  re- 
gional and  thus  there  may  l^e  even  extensive  cerebral 


ORGANIC   DEMENTIA  87 

involvement,  without  radial  indication.  A  liigli 
blood  pressure  has  been  held  suggestive,  but  it  is 
not  an  essential  point  in  the  diagnosis,  and  some  au- 
thorities have  found  it  absent  in  over  three-fourths 
of  such  cases. 

A  limited  portion  of  one  hemisphere  may  show 
well  developed  arteriosclerosis,  while  a  careful  au- 
topsy fails  to  find  evidence  of  arterial  change  in  any 
other  part  of  the  body.  Also  this  circumscribed  le- 
sion may  exhibit  mental,  motor  or  sensory  symp- 
toms, in  harmony  with  the  special  centers  involved. 

The  autopsy  findings  vary  with  the  localizing  in- 
cidents and  the  degree  of  the  degeneration  changes, 
which  may  be  most  marked  about  the  vessels  or 
close  to  the  cortex.  The  ventricles  may  be  dilated, 
local  hemorrhages  with  extensive  areas  of  softening- 
can  occur,  and  an  unevenness  in  the  distribution  of 
pathologic  tissue  is  the  rule. 

There  is  no  pathognomonic  symptom  and  between 
individual  cases  there  is  a  good  deal  of  difference. 
Often  there  is  lessened  energy  and  interest  in  work, 
together  with  forgetfulness  and  emotional  depres- 
sion, perhaps  also  sleeplessness  and  irritability. 
Headache,  dizziness  and  deafness  are  possible  com- 
plaints. The  dementia  is  progressive  and  shows  in  a 
growing  inefficienc}^,  in  the  loss  of  ability  of  emo- 
tional discrimination,  in  the  failure  of  comprehen- 
sion, and  in  incoherence  of  speech.    Hallucinations, 


00  :\IEXTAL    DISEASES 

delusions  and  a  further  confusion  of  thought  come 
for  some  cases.  Focal  degeneration  produces  a  dis- 
turbance according  to  the  area  involved.  Thus 
speech,  sight,  hearing  or  some  special  faculty  of  the 
mind  or  hand  may  be  lost.  The  end  condition  does 
at  times  leave  the  patient  disabled  and  entirely  de- 
pendent on  the  care  of  others. 

It  is  characteristic  for  these  patients  to  hold  well 
their  own  personality,  which  fact  becomes  a  point 
of  diagnostic  consequence,  for  in  senile  dementia 
this  is  less  true.  The  laboratory  report  helps  to 
separate  the  general  paretic. 

The  diagnosis  has  to  study  the  whole  picture  and 
then  eliminate  the  other  jDsychoses  which  come  up 
for  consideration. 

6.  Brain  Tumor. — Brain  tumors  do  not  always 
have  mental  symptoms.  Those  that  do,  usually 
either  touch  the  cortex  or  reach  it  by  pressure. 

Tuberculosis  and  syphilis  are  the  two  prominent 
infectious  causes,  while  in  addition  to  true  tumors 
there  can  occur  developmental  anomalies  and  aneu- 
rysms of  the  cerebral  vessels. 

Both  jDhysical  and  mental  findings  are  controlled 
by  the  location  and  size  of  the  tumor.  The  mental 
symptoms  are  not  enough  to  give  a  diagnosis;  that 
must  have  also  all  the  signs  available.  And  locali- 
zation calls  for  special  skill  in  the  study  of  the 
whole  picture,  for  which  reference  is  properly  made 


OlUiANlC    DEMEXTIA  89 

to  texts  of  a  differciit  soi't,  Avliicli  have  direct  re- 
,i;-ard  for  the  respoiisil^ility  of  the  surgeon. 

Headache  often  comes  early.  Nausea,  vomiting, 
dizziness,  convulsions,  paralysis,  dyspnea,  heart  dis- 
turbance and  optic  nerve  changes  are  suggestive 
symptoms  which  may  occur  in  any  combination,  or 
all  develop  together. 

When  a  mental  change  conies  it  is  of  a  sort  that 
could  belong  to  paresis  or  arteriosclerosis.  Atten- 
tion and  comprehension  are  at  fault;  the  patient  is 
slow  in  movement  and  thought,  showing  confusion, 
lack  of  interest  and  loss  of  energy;  moral  stand- 
ards are  lost  and  delusions  and  hallucinations  may 
be  present.  The  size  and  site  of  the  tumor  limit 
the  degree  of  disturbance,  and  the  symptom  group 
varies  for  each  patient. 

Multiple  sclerosis,  tuberculous  meningitis,  and 
hysteria  have  also  to  be  separated  in  the  diagnosis, 
which  the  laboratory  report  and  a  full  display  of  all 
signs  and  symptoms  help  to  get  through  elimination. 

7.  Brain  Abscess. — An  abscess  implies  infection 
and  in  the  brain  it  is  most  frequently  a  secondary 
development. 

There  are  not  always  mental  symptoms.  In  some 
cases  the  clinical  history  is  like  cerebral  tumor. 
Temperature  and  headache,  with  a  slow  pulse,  may 
mark  the  beginning.  Later  an  acute  case  can  go  to 
delirium  or  stupor. 


90  MENTAL   DISEASES 

8.  Cerebral  Apoplexy. — Arteriosclerosis  and  sj^dIi- 
ilis  are  tlie  diseases  most  frequently  responsible  for 
cerebral  apoplexy.  There  may  be  a  cardiovascular- 
renal  involvement.  A  high  blood  pressure  increases 
the  liability,  and  a  sudden  change  in  the  blood  pres- 
sure may  be  the  immediate  cause.  Under  the  term 
''apoplexy"  we  include  cerebral  hemorrhage,  throm- 
bosis and  embolism,  which  are  similar  in  the  clinical 
manifestation  by  which  the  disaster  is  announced; 
though  it  should  be  borne  in  mind  that  while  an  em- 
bolism is  abrupt,  and  a  hemorrhage  is  usually  so,  a 
thrombosis  is  of  variable  duration  in  its  develop- 
mental period.  This  is  often  followed  by  a  state  of 
confusion,  random  movements,  and  the  doing  of 
queer  or  unexpected  things.  The  later  condition  is 
made  by  the  residuals,  which  have  to  do  with  the 
preceding  disease  and  the  area  invaded.  A  careful 
estimation  of  these  remaining  s^Tiiptoms  sometimes 
can  make  localization  possible  and  indicate  the 
prognosis. 

9.  Cerebral  Trauma. — A  head  injury  can  be  of  any 
degree,  and  thus  the  range  of  s^miptoms  possible  in 
cerebral  trauma  is  indicated.  Further,  if  there  are 
complications,  such  as  hemorrhage  or  any  gross 
harm  to  brain  substance,  the  j^icture  shajDes  accord- 
ingly. Unconsciousness  may  follow  the  injury,  or 
a  mental  incapacity  come  on  later.  A  befogged  con- 
dition may  clear  slowly,  and  a  loss  of  memory  from 


ORGANIC   DEMENTIA 


91 


Fig.   23. — Organic  dementia,  cerebral   apoplexy. 


92  IMEXTAL    DISEASES 

the  time  of  the  accident  is  characteristic,  while  in 
some  few  cases  the  memory  loss  has  antedated  the 
accident,  including  a  period  of  a  week  or  more. 

The  extent  of  cerebral  cell  injury  rather  measures 
the  violence  of  the  trauma,  and  even  in  many  cases 
where  no  diagnosis  of  hemorrhage  is  made  it  is  pos- 
sible that  numerous  minute  scattered  hemorrhages 
have  occurred. 

A  change  in  character  is  usual,  along  with  phe- 
nomena of  various  sorts.  The  patient  often  shows 
weakness  in  ordinary  movements  and  suffers  from 
vertigo.  He  may  be  indifferent  and  passive  or  ir- 
ritable. Delusions  sometimes  come,  or  there  may 
be  a  fabrication  of  memory  and  rambling  speech. 
Disorientation,  dejection,  whining,  incoherence,  for- 
getfulness  and  tinnitus  are  other  possible  symptoms. 

An  illustration  of  this  type  of  a  case  is  given  in 
the  history  of  a  laborer  committed  to  the  Western 
State  Hospital  several  months  ago.  The  court  pa- 
pers indicated  that  not  much  was  known  of  the  man. 
His  mental  disturbance  had  been  increasing  through 
a  week.  He  was  confused,  rambling,  disconnected 
and  made  exaggerated  and  contradictory  statements. 
He  was  unable  to  find  his  way  about;  was  put  down 
as  dangerous  and  brought  to  the  asylum  with  the 
diagnosis  of  epilepsy.  The  records  here  show  that 
on  examination  it  was  impossible  to  obtain  any  de- 
pendable history.    After  admission  he  had  a  number 


OlUIAXJCl    DKMI'mTIA 


93 


Fig.   24. — Organic   dementia,    cerebral    trauma. 


94 


MENTAL   DISEASES 


Fig.   25. — Organic    dementia,    cerebral    trauma. 


ORGANIC   DEMENTIA  95 

of  severe  epileptiform  attacks.  The  befogged  con- 
dition was  slow  in  clearing ;  later  fabrication  of  mem- 
ory and  disorientation  as  to  time  and  place  and  per- 
sons were  evident,  and  judgment  delusional.  Blood 
pressure  was  systolic  210  mm.  The  patient  was  for 
some  time  considered  in  a  critical  condition,  and 
given  neutral  tub  treatment  in  the  hydrotherapy 
department. 

Through  the  month  after  admission  the  patient 
continued  very  much  confused,  but  became  able  to 
state  that  his  mind  had  been  blank  and  that  his  last 
recollection  while  outside  was  of  working  in  a  log- 
ging camp,  seeing  a  log  coming  towards  him,  and 
being  hit  on  the  head  by  the  steel  cable.  This  fact 
was  confirmed  by  outside  statement.  Two  weeks 
later  the  man  was  out  working  on  the  lawn,  able  to 
answer  questions  without  confusion,  eating  well  and 
sleeping  well,  and  was  without  further  seizures. 

Today  the  patient  does  not  recollect  his  coming 
to  this  hospital  nor  the  first  of  his  stay  here.  His 
manner  of  speech  is  quiet  and  straightforward. 
There  is  no  evidence  of  delusions.  Blood  pressure 
is  systolic  170  mm.  and  diastolic  115  mm.  The  pro- 
visional diagnosis  has  been  revised  to  organic  de- 
mentia, cerebral  trauma  (Diefendorf),  and  it  is  ex- 
pected that  he  will  soon  be  discharged. 


CHAPTER  X 

INVOLUTION  PSYCHOSES 

1.  Melancholia. 

2.  Presenile  Delusional  Insanity. 

3.  Senile  Dementia. 

Various  kinds  of  insanity  may  happen  to  come  to 
a  patient  who  has  reached  the  period  of  physiologic 
involution,  but  melancholia,  presenile  delusional  in- 
sanity and  senile  dementia  are  forms  which  have  to 
do  directly  with  the  involution  changes. 

1.  Melancholia. — By  some  it  is  claimed  that  mel- 
ancholia is  a  type  of  the  manic  depressive  group 
modified  by  the  changes  of  the  involution  period  in 
which  the  ductless  glands  ma}^  figure,  but  this  is 
not  established  beyond  dispute. 

Melancholia  is  a  psychosis  characterized  by  anxi- 
ety, despair,  and  a  grave  persistent  depression,  to- 
gether with  a  suppressed  agitation  that  shows  phys- 
ically in  muscular  tension  and  increased  psj^cho- 
motor  activity.  It  is  a  chronic  disease,  usually  slow 
in  development  and  rather  free  from  marked  varia- 
tions in  its  course.  The  beginning  comes  often  in 
the  sixth  decade;  nearly  two-thirds  of  the  patients 

96 


INVOLUTION    rSYOnOSES 


97 


Fig.    26. — Involution    psychoses,    melancholia. 


98  MENTAL   DISEASES 

are  women,  and  about  one-third  go  on  to  recovery. 
Neglect  of  work,  indifference  to  the  regular  inter- 
ests of  life  and  anxious  worrying  are  early  findings 
which  may  be  accompanied  by  numerous  physical 
discomforts  and  mental  faults.  Hallucinations  are 
rather  the  rule,  and  may  give  the  foundation  for 
the  delusions  that  follow.  Self-condemnation  often 
is  a  prominent  sjanptom ;  and  a  readiness  to  go  with- 
out food  can  cause  a  loss  in  weight.  The  despond- 
ency is  of  a  sort  that  does  not  lighten  in  response  to 
incident  or  effort. 

The  joossibility  of  suicide  is  the  great  danger  that 
must  be  held  in  mind,  because  frequently  this  is  a 
compelling  thought,  while  the  patient  has  the  men- 
tality and  physical  ability  that  is  sufficiently  respon- 
sive to  carry  out  such  a  threat. 

Arteriosclerosis,  some  nerve  cell  degeneration,  and 
limited  atrophy  of  the  brain  are  the  most  frequent 
autopsy  findings. 

Mrs.  H.,  who  came  to  this  hospital  in  1913,  was 
then  quiet,  orderly  and  depressed.  She  was  near 
fifty,  had  grieved  greatly  over  the  death  of  her  hus- 
band, and  talked  of  killing  herself.  When  nerv- 
ous she  saw  and  heard  all  kinds  of  things.  Sexual 
excitement  was  marked.  She  had  somatic  delusions 
and  said  she  had  blood  poisoning  and  cancer.  Then 
there  were  restless  spells  and  a  strong  craving  for 


xvoi.uTioN   l's^■(;ll()SKs 


09 


Fig.   27. — Involution   psychosis,  melancholia. 


100  MEXTAL   DISEASES 

sedatives.  Slie  at  times  "would  bite  herself,  and  at 
night  sometimes  saw  skeletons  dancing  about  the 
room.  Also  she  seemed  conscious  of  the  presence 
of  her  dead  husband,  and  had  delusions  that  grew 
out  of  hallucinations.  There  was  a  period  of  im- 
provement, but  later  she  failed  again.  There  was 
loss  in  weight  and  increase  in  depression;  she  grew 
noisy  and  had  unclean  habits.  She  complained  of 
a  devil  in  her  throat  urging  her  to  kill. 

2.  Presenile  Delusional  Insanity. — Presenile  delu- 
sional insanity  is  an  infrequent  diagnosis.  It  usu- 
ally begins  in  the  fourth  decade  with  symptoms  that 
suggest  a  dementia  precox  modified  by  the  change 
of  adult  life.  The  prominent  symptoms  are  irrita- 
bility, with  a  progressive  dementia  that  allows  a 
great  variety  of  unstable  delusions.  These  delu- 
sions may  have  to  do  with  bodily  derangements, 
suspicion,  persecution  or  infidelity.  Charges  of  un- 
speakable conduct  will  not,  however,  hold  the  pa- 
tient from  his  usual  association  with  the  persons 
involved.  The  orientation  stays- normal.  The  con- 
duct shows  a  general  irresponsibility. 

3.  Senile  Dementia. — For  patients  around  sixty 
years  of  age,  one  of  the  most  frequent  conditions 
leading  to  conunitment  is  senile  dementia.  The 
organic  changes  upon  which  this  jDsychosis  depends 
are  of  a  progressive  sort.     General  atrophy  of  the 


INVOLUTION    PSYCHOSES 


101 


Fig.   28. — Involution   psychosis,   presenile    delusional    insanity. 


102  MENTAL   DISEASES 

brain  is  definite  and  characteristic.  There  is  an  in- 
crease of  the  cavity  fluid,  cell  degeneration,  arterio- 
sclerosis, and  sometimes  minute  scattered  hemor- 
rhages. 

Some  authors  do  not  formall}^  recognize  this  psy- 
chosis; others  go  into  subdivisions.  At  any  rate 
the  patients  for  sucli  a  group  are  here  in  the  hos- 
pital; they  are  too  difficult  to  be  taken  care  of  at 
home. 

Some  hereditary  tendency  and  a  high  blood  ipves- 
sure  are  often  in  the  background,  while  sickness, 
mental  strain,  or  other  hardship  may  be  the  precipi- 
tating incident. 

Recovery  is  not  expected.  There  is  gradually  in- 
creasing evidence  of  the  disease.  Most  such  cases 
are  in  the  hospital  less  than  five  years.  The  mem- 
ory is  bad  for  recent  events,  but  dwells  more  in  the 
early  past.  The  patient  comes  to  live  in  the  past 
and  this  fault  in  memor}^  may  in  some  considerable 
degree  be  a  factor  in  the  conduct,  which  shows  er- 
rors in  judgment,  careless  improprieties  and  per- 
haps a  tendency  to  be  negligent,  to  destroy  or  to 
pilfer.  The  thought  processes  are  slow  and  show 
confusion.  The  mood  shifts  and  may  be  irritable 
or  despondent.  Distrust  and  suspicion  will  some- 
times color  the  delusions  that  may  grow  out  of  il- 
lusions or  hallucinations.    A  broken,  restless  night 


INVOLUTION   PSYCHOSES 


103 


Fig.  29. — Involution  psychosis,  senile  dementia. 


104  MENTAL   DISEASES 

in  which  the'  different  symptoms  are  worse  is  the 
rule,  as  is  also  a  daytime  drowsiness. 

Among  the  jDhysical  signs,  high  pulse  pressure, 
tremors,  joartial  paralysis,  tinnitus,  diminished  sen- 
sibilit}^,  and  small,  uneven  pupils  often  occur. 


CHAPTEE  XI 

CONSTITUTIONAL  INFERIORITY  AND  DEFEC- 
TIVE MENTAL  DEVELOPMENT 

1.  Constitutional  Inferiority. — Constitutional  in- 
feriority is  a  name  that  may  be  used  in  classification 
for  a  group  allowed  arbitrarily  to  include  certain 
borderline  psychopathic  states.  Most  of  the  cases 
thus  considered  are  weak  individuals  with  a  defec- 
tive heredity,  who  have  often  suffered  further  in  an 
unfortunate  environment.  The  evident  fault  may 
go  in  one  direction  or  another  and  get  some  further 
name  according  to  the  psychopathic  feature  that  is 
made  prominent.  Nervousness,  dejection,  excite- 
ment, compulsion  neurosis,  and  sexual  perversions 
are  manifestations  that  mark  different  types.  Of 
course,  many  such  individuals  are  in  their  own 
homes,  but  when  the  difficulty  of  their  care  and  con- 
trol passes  a  certain  point  it  becomes  necessary  to 
provide  institutional  supervision. 

2.  Defective  Mental  Development. — Defective 
mental  development  differs  from  dementia  in  that 
the  individual  never  has  had  ordinary  mentality. 

105 


106 


MEJ^ITAL   DISEASES 


Fig.  30. — Constitutional  inferiority.     Note  jug  handle  ears. 


DEFECTIVE    MENTAL    DEVELOPMENT 


107 


There  are  different  grades;  the  most  severe  is  called 
idiocy  and  hardl}^  goes  beyond  mere  existence,  an 
adult  going  no  further  in  development  than  a  child 


iM«.  :a.—c< 


iliiiiiul    inferiority. 


of  three.  A  better  ability,  but  one  that  does  not  go 
beyond  the  age  of  seven,  can  belong  to  an  imbecile, 
while  the  term  "moron"  or  high  grade  imbecile  is 


108 


MEXTAL   DISEASES 


Fig.    32. — Defective    mental    development,    imbecility. 


DEFECTIVE    MENTAL    DEVELOPMENT 


109 


used  hy  some  when  the  ability  corresponds  with  that 
of  a  cliihl  Ix'tweeii  seven  and  twelve  years  of  age. 


Fig.   33. — Defective  mental   development.      See  doll  in  hand. 


The  imbecile  is  usually  recognized  in  childhood. 
He  shows  variations  from  normal  conduct,  may  be 
morbidly  stupid  or  overactive  and  irritable;  often 


IIU 


MEXTAL   DISEASES 


shows  a  lack  of  sense  of  responsibility  and  an  incli- 
nation towards  many  improprieties. 


Fig.   34. — Defective    mental    development. 

Usually  an  imbecile  will  make  some  improvement 
under  instruction,  but  does  not  develop  enoug'li  to 
take  care  of  himself. 


CHAPTER  XII 

INTOXICATION  PSYCHOSES 

1.  Acute  Alcoholic  Intoxication. 

2.  Chronic  Alcoholism. 

3.  Delirium  Tremens. 

4.  Korsakow's  Psychosis. 

5.  Acute  Alcoholic  Hallucinosis. 

6.  Alcoholic  Hallucinatory  Dementia. 

7.  Alcoholic  Paranoia. 

8.  Alcoholic  Paresis. 

9.  Alcoholic  Pseucloparesis. 

10.  Morphinism. 

11.  Cocainism. 

1.  Acute  Alcoholic  Intoxication. — For  certain  in- 
dividuals, the  effect  of  alcohol  taken  freel}^  regularly 
goes  beyond  what  may  be  termed  physiologic  drunk- 
enness, and  in  these  cases  acute  alcoholic  intoxica- 
tion is  properly  put  as  a  psychosis. 

The  pathologic  evidence  comes  with  the  extreme 
exhibition  of  particular  symptoms,  as  anger  which 
may  lead  to  violence,  or  despondency  with  attempts 
at  suicide,  or  destructive  acts,  or  a  shamelessness 
that  has  no  reserve,  and  instances  of  this  type  can 

111 


112  MEl^TAL   DISEASES 

be  expected  to  repeat  this  picture  whenever  the  cir- 
cumstances are  favorable. 

2.  Chronic  Alcoholism. — Tolerance  for  alcohol  va- 
ries greatly,  but  where  used  persistently  it  marks 
more  or  less  every  organ  in  the  body.  There  are 
demonstrable  changes  in  the  brain  and  cord.  In- 
flammation of  the  membranes,  some  general  atrophy, 
dilatation  of  the  ventricles,  and  localized  arterio- 
sclerosis are  among  the  findings. 

The  heredity  is  often  bad,  and  drinking  habits  on 
the  part  of  the  father  are  common  enough  to  be  sig- 
nificant. 

The  mental  deterioration  is  slowly  progressive. 
It  becomes  hard  to  give  attention  to  the  matter  in 
hand.  Inditference,  forgetfulness,  negligence,  and 
irritability  may  be  associated  with  faults  in  judg- 
ment and  an  open  disregard  for  customary  i^ropri- 
eties.  Illusions,  hallucinations  and  delusions  of  jeal- 
ousy are  all  possibilities.  Also  there  are  physical 
signs.  Perhaps  the  most  characteristic  is  the  fine 
tremor  that  shows  best  in  the  hand,  and  thus  in  the 
writing.  There  are  various  disturbances  in  the  sen- 
sibility of  the  skin.  Partial  paresis,  and  lesions  of 
the  optic  nerve  and  retina  can  happen,  and  occasion- 
all}^  there  are  convulsions. 

This  dementia  is  like  others  in  being  gradually 
progressive,  but  differs  in  having  its  alcoholic  his- 
tory which  is  essential  to  the  diagnosis. 


INTOXICATION    PSYCHOSES  113 

Chronic  alcoholism  provides  the  foundation  upon 
which  several  of  the  intoxication  forms  can  develop, 

3,  Delirium  Tremens. — Delirium  tremens  comes  to 
those  who  are  chronic  users  of  liquor,  often  at  the 
time  of  a  debauch,  but  alcohol  alone  is  not  a  suffi- 
cient cause.  Usually  the  history  gives  additional 
circumstances  that  overstrained,  weakened,  or 
shocked  the  individual  and  produced  functional  dis- 
turbance. 

The  beginning  may  be  abrupt,  but  prodromal  rest- 
lessness, loss  of  appetite,  irritability,  and  insomnia 
are  the  rule,  and  there  may  also  be  a  definite  dislike 
for  liquor  expressed. 

The  mental  disturbance  that  follows  is  marked  by 
vivid  hallucinations  of  which  there  is  a  great  vari- 
ety; cannons  and  bells,  angels  or  devils,  monkeys 
and  snakes  are  more  or  less  common.  The  illusions 
may  show  as  a  tendency  to  see  spots  and  believe 
them  crawling.  The  delusions  are  shifting.  They 
may  be  fanciful  and  grotesque  and  commonly  dis- 
play fear.  The  patient  frequently  shows  anxiety 
and  excitement,  but  occasionally  is  inclined  to  be 
jovial.  And  along  with  all  of  this  there  is  a  definite 
confusion  which  leads  into  delirium.  Sometimes 
there  are  lucid  intervals.  The  part  of  the  memory 
best  held  is  for  the  remote  past. 

Physically  there  is  the  tremor  of  small  muscles 
that  shows  specially  in  the  hand,  face  and  tongue. 


ll-i  MENTAL   DISEASES 

Fever,  albuminuria,  double  siglit  and  parasthesias 
are  other  findings. 

The  prognosis  is  good  for  nine  out  of  ten.  Some 
go  quickly  to  the  fatal  end. 

4.  Korsakow's  Psychosis. — In  Korsakow's  psycho- 
sis there  is  a  lack  of  impressibility,  a  loss  of  memory 
for  recent  events,  together  with  a  fabrication  that  is 
characteristic.  The  case  is  nearly  always  one  of 
chronic  alcoholism  with  the  signs  of  a  poljaieuritis. 
There  ma}^  have  been  recurrent  delirium  tremens, 
but  other  intoxications  sometimes  give  the  apparent 
cause,  and  further  instances  are  reported  as  occur- 
ring in  paresis  and  senile  dementia. 

The  pathologic  changes  mark  both  brain  and  cord, 
and  are  of  a  sort  that  might  belong  with  a  severe 
alcoholic  toxemia.  Minute  cerebral  hemorrhages 
can  explain  the  variety  of  focal  symptoms. 

The  lack  of  impressibility  is  perhaiDS  responsible 
for  the  loss  of  memory  for  recent  events,  and  also 
for  the  confused  orientation.  It  is  characteristic 
that  lapses  in  thought  bring  out  fabrications.  These 
are  often  far  away  from  the  facts,  but  are  plausibly 
put,  and  even  when  outlandish  or  impossible  seem 
to  fully  satisfy  the  patient.  This  tendency  to  fab- 
rication can  usually  be  further  drawn  out  by  ques- 
tions. In  other  connections  the  judgment  may  be 
apparently  normal. 


iNTOxr(;ATi()X  psy(Utof;ks  115 

The  mood  of  different  patients  or  of  the  same  pa- 
tient at  different  times  may  indicate  anxiety,  indif- 
ference, apathy,  irritability,  or  good  hnmor.  Some 
make  a  gradual  improvement,  onongh  so  that  they 
can  again  take  np  th(Mr  work,  l)nt  more  develop  a 
dementia  that  goes  away  from  recovery. 

5.  Acute  Alcoholic  Hallucinosis. — Hallucinations 
of  hearing,  leading  to  delusions  of  persecution, 
nearly  always  mark  the  beginning  of  an  acute  alco- 
holic hallucinosis.  Conversations  are  overheard  in 
which  all  manner  of  evil  statements  are  made  con- 
cerning the  patient  and  his  affairs.  These  delusions 
may  quickly  develop  some  loose  paranoid  jDattern. 

The  commencement  is  usually  abrupt  and  the  an- 
tecedent history  alcoholic.  Often  there  is  insomnia, 
anorexia,  loss  in  weight,  and  a  tremor  of  hands  and 
tongue,  but  on  the  whole  the  ]3hysical  signs  are  not 
marked  and  the  patient  is  rather  free  from  restless- 
ness. 

The  relation  to  delirium  tremens  is  close,  and  there 
are  borderline  cases,  but  in  acute  alcoholic  psychosis 
there  is  relative  freedom  from  disorientation,  cloud- 
ing of  consciousness,  and  physical  disturbances. 
Further,  the  prominent  and  characteristic  hallucina- 
tions are  those  of  hearing. 

The  prognosis  looks  to  a  recovery  made  after  sev- 
eral weeks,  but  some  cases  become  chronic. 


IIG  MEXTAL   DISEASES 

6.  Alcoholic  Hallucinatory  Dementia. — When  de- 
lirium tremens  or  acute  alcoholic  hallucinosis  par- 
tially clears  only  to  later  lapse  into  a  chronic  state 
marked  with  hallucinations  and  giving  general  evi- 
dence of  dementia,  the  diagnosis  may  be  revised  to 
alcoholic  hallucinatory  dementia,  and  certain  other 
cases  may  be  put  here  without  a  reclassification. 
The  patient  hears  voices  that  threaten  him,  in  imag- 
ination he  suffers  at  the  hands  of  his  persecutors 
physical  harm  as  well  as  indignities  of  various  sorts. 
The  delusions  tend  to  become  of  paranoid  type,  are 
more  or  less  persistent  and  are  kept  up  without 
much  change.  Frequently  they  concern  the  body 
and  may  show  some  sexual  phase.  Anxiety  or  irri- 
tability may  mark  the  conduct  at  first,  but  later  there 
is  generally  some  humor  in  the  attitude. 

Without  alcohol,  progress  may  be  stopped,  but 
real  recovery  is  not  expected. 

7.  Alcoholic  Paranoia. — Delusions  of  a  paranoid 
type  occur  with  several  different  psychoses.  When 
a  chronic  alcoholic  condition  is  responsible,  the  de- 
scriptive term  "alcoholic  paranoia"  can  be  used. 

In  such  a  case  delusions  of  jealousy  are  often  con- 
nected with  circumstances  that  permit  the  possibil- 
ity of  the  charges  made,  but  the  reasons  given  are 
not  of  a  sort  to  carry  conviction  and  may  be  entirely 
absurd.  Thus,  some  trivial  incident  may  be  men- 
tioned as  proof  of  infidelity.     It  is  characteristic 


INTOXICATION    PSYCHOSES 


117 


that  the  most  grave  statements  made  do  not  dis- 
turb the  readiness  of  the  patient  to  associate  in  or- 


Fig.   35. — Intoxication    psychosis,     alcholic    hallucinatory    dementia. 

dinary  manner  with  those  whom  he  accuses.  Hal- 
lucinations of  hearing  are  at  times  present.  Es- 
trangements within  the  family  can  be  understood. 


118  MEI^TAL   DISEASES 

AVitli  alcohol  taken  away,  temporary  improvement 
is  expected,  but  not  recovery. 

8.  Alcoholic  Paresis. — ^AYhile  a  diagnosis  of  alco- 
holic paresis  has  sometimes  been  used,  it  is  probably 
better  that  such  a  case  should  be  known  as  paresis, 
with  certain  extra  findings  for  which  alcohol  is  re- 
sponsible, as  delusions  and  hallucinations  of  infi- 
delity, the  alcoholic  tremor,  and  neurotic  s^inptoms. 
However,  it  must  be  borne  in  mind  that  according  to 
circumstances  the  alcoholic  picture  or  the  paresis 
may  develo^D  first. 

9.  Alcoholic  Pseudoparesis. — Certain  instances  of 
marked  alcoholism  may  simulate  i)aresis.  Chronic 
alcoholism  with  a  sudden  beginning  of  mental 
disturbance,  carelessness  of  manner,  feelings  of 
well-being,  delusions  of  grandeur,  pupillary  varia- 
tions, a  muscular  fault  that  shows  in  speech,  writing 
and  gait,  together  Avith  tremors  and  painful  joints, 
makes  proper  the  name  "alcoholic  pseudoparesis." 

A  differential  diagnosis  notes  the  history,  the  gen- 
eral prompt  imiDrovement  when  liquor  is  stopped, 
and  the  laboratory  examinations  of  blood  and  spinal 
fluid.  ATitli  alcohol  stopped,  the  patient  goes  on  to 
recovery  or  develops  some  degree  of  a  chronic  alco- 
holic dementia. 

10.  Morphinism. — In  this  country  morphinism 
nearly  always  has  begun  in  the  taking  of  the  drug 
to  relieve  pain.     The  susceptibility  of  different  in- 


INTOXICATION   PSYCHOSES  119 

dividuals  varies  mucli.  Often  the  habit  is  estab- 
lished before  it  attracts  attention.  A  weakness  that 
is  muscular,  mental  and  moral  conies  gradually. 
Temporary  stimulation  is  obtained  from  each  in- 
jection, but  is  followed  by  a  period  of  reaction  to 
which  belong  all  the  disturbances  due  to  toxemia 
and  the  craving  that  can  only  be  allayed  by  a  grad- 
ually increasing  dose,  which  may  go  to  forty  grains 
or  more.  If  there  be  such  a  thing  as  a  truth  center 
in  the  brain  it  is  certainly  injured  by  the  use  of  this 
drug.  At  first  for  gratification,  but  soon  to  vainly 
diminish  the  distressing  urge,  it  is  taken.  Some  ob- 
servers, however,  believe  that  heroine  still  more 
readily  leads. to  moral  insanity. 

Irritability  is  usual,  also  faults  of  judgment,  lack 
of  purpose,  and  mental  enf eeblement ;  some  cases 
show  illusions  and  delusions. 

Morphine  locks  up  the  secretions,  contracts  the 
pupils,  and  gives  an  itchy,  dry  skin  which,  when  a 
localized  symptom,  takes  the  hand  frequently  to  the 
nose.  There  are  many  incidental  discomforts,  with 
a  tendency  to  complain  of  the  same.  Often  the  skin 
gives  plain  evidence  of  repeated  hypodermic  punc- 
ture. 

Examination  has  found  albumin  and  glycosuria. 
Ataxia,  cachexia  and  collapse  are  possibilities. 

With  the  full  removal  of  the  drug  there  can  be 
recover}^,  but  the  liability  to  recurrence  is  great. 


120  MENTAL  DISEASES 

11.  Cocainism. — Cocainism  is  rather  usually  com- 
plicated by  the  taking  of  some  other  drug  as  mor- 
phine. The  symptoms  are  for  the  most  part  those 
of  morphine,  but  the  developments  towards  disturb- 
ance come  quickly.  Hallucinations  are  likely  to 
be  vivid,  and  frequently  the  sensation  of  objects  felt 
beneath  the  skin  is  distinctive.  Delusions  of  a  dis- 
turbing sort  may  have  to  do  with  persecution  or  in- 
fidelity. The  patient  is  overenergetic  but  fails  to 
accomplish  much.  The  degree  of  excitement  leads 
to  uncontrolled  and  bizarre  conduct.  Cocaine  di- 
lates the  pupils.  Abstinence  from  the  drug  promptly 
brings  mitigation  of  its  effect,  but  the  permanency 
of  recoverv  is  alwavs  doubtful. 


CHAPTER  XIII 

THYROIGENOUS  PSYCHOSES 

1.  Myxedema. 

2.  Cretinism. 

Both  myxedema  and  cretinism  are  understood  to 
be  conditions  that  develop  because  of  a  failure  in 
the  internal  secretion  of  the  thyroid  gland,  which  as 
a  hormone  ma}^  control  processes  of  growth  in  other 
tissues. 

1.  Myxedema. — Myxedema  following  surgical  re- 
moval of  the  thyroid  gland  has  made  an  opportunity 
to  study  the  group  of  symptoms.  Now  operative 
myxedema  is  rare,  but  the  full  relation  of  the  gland 
to  the  idiopathic  type  is  established.  Adolescence 
or  later  is  the  usual  time  of  beginning.  Often  the 
rough,  thickened  skin  comes  first  along  with  the 
atrophy  of  the  gland.  Hands  are  thick  and  clumsy; 
genital  anomalies  are  frequent;  the  bones  thicken 
and  fail  in  development.  Lumpy,  large,  fatty  masses 
may  show  in  the  supraclavicular  spaces  or  on  the 
arms.  Metabolism  is  slowed  and  leads  to  faults  in 
digestion.  Faults  in  nourishment  show  sometimes 
with  the  nails  brittle,  the  hair  dry,  and  the  teeth 

121 


122  MENTAL   DISEASES 

loosened.  The  movements  seem  slow  and  difficult. 
The  mental  action  also  drags  and  suggests  a  lack 
of  interest.  The  degree  of  mental  and  physical 
changes  varies  from  a  mere  stiffness  in  manner  and 
thought  to  restlessness  with  insomnia,  anxiety,  and 
delusions,  that  indicate  the  mental  possibilities  of 
this  psychosis.  The  blood  has  eosinophiles.  White 
and  Jelliffe  give  a  congenital  form  that  near  the  time 
of  weaning  develops  rapidly,  but  usually  does  not 
live  to  grow  up. 

2.  Cretinism. — The  word  "cretinism"  is  allowed 
as  the  name  for  a  condition  marked  by  the  display  of 
certain  mental  and  |)hysical  changes,  beginning  in 
the  very  young  and  being  slowly  progressive.  The 
cause  is  thjT^oid  defect  in  function;  and  one  theory 
is  that  this  is  the  effect  of  some  water-borne  noxious 
element,  got  from  the  ground  in  certain  districts. 

This  so-called  '^endemic  cretinism"  has  the  bones 
shortened,  with  various  anomalies  and  deformities. 
The  skin  is  thick,  loose  and  wrinkled.  The  neck  is 
short  and  thick,  the  face  swollen,  the  tongue  thick, 
and  the  whole  figure  clumsj'.  The  sex  organs  fail 
in  normal  growth.  Nutritive  processes  are  sluggish. 
The  child  is  apathetic  and  dully  inactive.  Arrested 
development  is  apparent.  Frequently  there  is  sen- 
sory impairment,  especially  of  hearing.  The  men- 
tal evidence  is  a  mass  of  faults,  but  there  is  much 
difference  between  individuals;  some  never  reach 


THYROKIENOUS    PSYCIIO.SKS 


123 


Fig.   36. — Taken    at   age    of    5    years.      Thyrogenous   psychosis,    cretinism. 


124  MENTAL   DISEASES 

coherent  speech,  while  others  are  even  near  normal. 
There  may  be  goiter  with  decreased  secretion,  or 
atrophy  of  the  thyroid,  and  frequently  the  hypo- 
physis is  enlarged.  Early  injury  to  the  gland  can 
cause  sporadic  cretinism.  Also  aberrant  types  oc- 
casionally occur. 


CHAPTER  XIV 

INFECTION  AND  EXHAUSTION 
PSYCHOSES 

(a)  Infection  Psychoses. 

1.  Fever  Delirium. 

2.  Infection  Delirium. 

3.  Postinfection  Psychosis. 

(b)  Exhaustion  Psychoses. 

1.  Collapse  Delirium. 

2.  Acute    Confusional    Insanity. 

3.  Acquired  Neurasthenia. 

When  an  infection  is  at  all  serious  it  develops 
some  degree  of  exhaustion;  also  where  exhaustion 
lowers  the  resistance  the  liability  to  infection  is  in- 
creased. Thus  infection  psychosis  and  exhaustion 
psychosis  often  overlap  and  have  their  symptoms 
entangled.  However,  this  occurrence  may  not  hap- 
pen, so  the  conditions  are  separately  described,  with 
recognition  of  several  clinical  groups. 

Infection  Psychoses 

1.  Fever  Delirium  is  a  mental  disturbance  that  ac- 
companies fever,  and  the  degree  of  resistance  to 

125 


12n  MEXTAL   DISEASES 

its  development  indicates  tlie  measure  of  mental 
stability.  The  duration  has  somewhat  to  do  with 
the  picture  because  this  is  inclined  to  bring  symp- 
toms rather  in  a  routine  order.  Four  grades  are 
observed.  The  beginning  has  sensitiveness  to  light 
and  noise,  headache,  restlessness  and  insomnia;  the 
second  has  confusion  and  hallucinations;  in  the 
third,  motor  symptoms  are  increased  and  lack  con- 
trol; while  in  the  fourth  consciousness  is  dulled,  the 
movements  have  no  i^urpose,  the  muttering  is  in- 
coherent, and  coma  with  death  then  expected. 

2.  Infection  Delirium  names  the  mental  state  that 
may  come  in  an  early  stage  of  infection,  the  cause 
of  which  brings  the  typical  signs  of  its  own  disease. 
Distention  of  the  blood  vessels  in  the  cortex  may  be 
responsible  for  confusion  of  thought,  disorientation, 
excitement,  flight  of  ideas,  hallucinations  and  delu- 
sions. 

3.  Postinfection  Psychosis  indicates  an  exhaus- 
tion, or  the  continued  effect  of  a  toxemia  not  fully 
cleared  away.  The  patient  fails  to  get  back  his  for- 
mer interest  and  energy.  The  mood  is  sad.  There 
may  be  shifting  hallucinations.  With  a  further  de- 
velopment there  often  are  delusions  of  persecution, 
disturbing  voices,  and  grinning  faces.  The  one  who 
suffers  thus  may  be  quarrelsome  or  tempted  to  sui- 
cide. 


INFKCTroN    AXI)    FA'TTAI'STTON    PSYCTTOSES  127 

Exhaustion  Psychoses 

1.  Collapse  Delirium  is  infrequent.  Loss  of  blood 
and  shock  are  tlie  principal  causes,  and  infection 
can  indirectly  have  an  influence.  Everything  seems 
changed  and  gives  reason  for  perplexity.  Restless- 
ness, insomnia,  and  confusion  are  common.  Violent 
psychomotor  activity,  full  disorientation,  incoher- 
ence, illusions,  hallucinations,  and  delusions  are  all 
possible. 

2.  Acute  Confusional  Insanity  has  causes  such  as 
loss  of  blood,  illness,  and  mental  strain.  Perplexity 
is  apparent.  There  is  clouding  of  consciousness  with 
motor  excitement  and  incoherence.  The  whole  pic- 
ture is  not  as  abrupt  or  acute  as  in  the  case  of  col- 
lapse. Anxiety,  restlessness,  forgetfulness,  prostra- 
tion, various  physical  discomforts,  also  mental  faults 
due  to  confusion,  emotional  unevenness,  and  lucid 
intervals  are  all  among  the  findings  occasionally 
recorded.  The  course  of  such  psychosis  usually  lies 
within  a  three  months  period. 

3.  Acquired  Neurasthenia  is  a  term  that  may  be 
used  for  chronic  nervous  exhaustion.  It  is  a  condi- 
tion that  belongs  usually  to  the  period  most  exposed 
to  extra  mental  strain,  which  is  between  twenty- 
five  and  forty-five.  An  early  training  that  lacks 
discipline,  and  allows  a  deficiency  in  character  de- 
velopment, increases  the  liability.    Heredity  can  pro- 


128  MENTAL    DISEASES 

vide  a  predisposition,  and  an  irregular  life  tends  to 
lessen  normal  resistance.  The  provoking  cause  can 
be  overwork,  but  often  it  has  also  to  do  with  the 
continued  effort  made  to  meet  the  various  demands 
that  overcrowd  daily  life.  In  this  connection  it  is 
to  be  kept  in  mind  that  there  is  a  great  difference 
between  individuals  as  to  what  constitutes  over- 
work. 

In  some  measure  the  condition  is  the  direct  out- 
come of  the  fatigue  of  a  nervous  system  that  has  not 
been  allowed  sufficient  relaxation,  but  it  is  more  to 
be  regarded  as  a  chronic  intoxication  to  which 
various  irregularities,  both  nervous  and  physical, 
have  contributed. 

Because  of  the  circumstances,  the  beginning  can 
not  belong  to  any  exact  date.  The  individual  per- 
haps, grows  irritable,  and  is  inclined  to  a  tiredness 
that  is  all  out  of  proportion  to  what  has  been  done. 
Thinking  becomes  an  effort,  attention  is  difficult  and 
easy  distractibility  evident.  It  costs  an  effort  to 
stay  at  regular  work.  Amusement  does  not  rouse 
the  interest.  There  is  a  variety  of  physical  faults, 
especially  functional  disturbances.  Head  pains  are 
frequent,  and  deficiencies  in  elimination  far  reach- 
ing in  their  consequences.  Discomforts  of  all  sorts 
are  exaggerated  so  constantly  that  this  is  a  point 
in  differential  diagnosis.  Patients  show  anxiety  as 
to  their  health.    Usually  they  appreciate  their  own 


INFECTIOiSr    AND    EXHAUSTION    PSYCHOSES  129 

inefficiency,  and  worry  over  the  fact.  Emotional  in- 
stability shows  with  impulsiveness.  Usual  results 
in  work  are  not  reached.  There  may  be  noted  ab- 
normalities in  sensation.  Broken  nights  tend  to  in- 
crease the  apparent  nervousness.  Muscle  twitching 
and  a  tremor  in  the  eyelids  and  hands  are  possible 
incidents.  Disturbances  in  digestion  can  be  expected 
to  bring  a  certain  train  of  symptoms.  Such  patients 
are  inclined  to  demand  much  of  others,  without 
seeming  to  realize  the  unreasonableness  thus  shown. 
The  findings  all  put  together  shape  a  new  picture 
for  each  separate  case,  and  diagnosis  must  then 
eliminate  the  different  forms  of  dementia.  If  the 
cause  can  be  recognized  and  sufficiently  mitigated, 
then  the  prognosis  may  become  favorable. 


CHAPTEE  XV 

PSYCHOGENIC  NEUEOSIS 

1.  Hysterical  Insanity. 

2.  Traumatic  Neurosis. 

3.  Dread  Neurosis. 

1.  Hysterical  Insanity  is  the  name  used  to  desig- 
nate a  certain  mental  state  that  becomes  responsible 
for  a  kaleidoscopic  display  of  physical  symptoms 
which  suggest  particularly  a  lack  in  normal  control. 
It  is  possible  that  the  best  explanation  has  to  do  with 
a  dissociation  within  the  personality  of  the  indi- 
vidual. 

The  origin  of  the  word  carries  the  ancient  Greek 
belief  that  the  cause  lay  in  the  womb,  while  the  pres- 
ent teaching  considers  the  influence  of  repression 
in  the  sexual  sphere. 

The  subnormal,  poorly  endowed,  and  unevenly 
balanced  constitution  is  most  exposed  to  this  psy- 
chosis. 

The  symptoms  are  of  a  sort  calculated  to  attract 
attention  and  gain  sympathy.  There  is  often  an  evi- 
dent emotional  excitement  that  can  lead  to  impul- 
sive acts.    Actual  occurrences,  incidental  hardships 

130 


PSYCHOGENIC    NEUROSIS  131 

or  illnesses,  are  liable  to  gross  exaggeration,  with 
emphasis  being  given  to  unimportant  detail.  Such 
patients  complain  about  trifles  and  do  not  get  away 
from  a  self-consciousness  that  gives  an  ill-founded 
importance  to  all  that  concerns  them. 

The  physical  symptoms  also  are  manifold  and  in- 
clude various  erratic  sensory  disturbances.  The  list 
of  possible  symptoms  is  indefinite,  but  all  the  way 
through  it  is  characteristic  that  the  relation  of  cause 
and  effect  demanded  by  physiology  and  anatomy 
is  disregarded. 

The  degree  of  development  varies  with  the  pa- 
tient, but  some  reach  a  befogged  state  marked  by 
silly  excitement  or  epileptiform  convulsions.  This 
psychosis  belongs  to  youth  or  adult  life.  The  course 
is  not  progressive.  The  prognosis  as  to  any  period 
of  special  development  is  good,  but  the  chance  of 
recurrence  is  accepted. 

2.  Traumatic  Neurosis. — One  author  gives  trau- 
matic hysteria  as  a  synonym  for  traumatic  neurosis 
and  develops  the  subject  accordingly;  another  al- 
lows traumatic  neurosis  to  have  traumatic  neuras- 
thenia and  traumatic  hysteria  as  subdivisions,  and 
believes  the  definition  should  be  broad  enough  to 
include  the  result  of  psychic  as  well  as  physical 
shock;  a  third  puts  traumatic  neuroses  and  psycho- 
ses together  in  the  title  of  a  chapter ;  while  a  fourth 
quite  rearranges  the   grouping.     However,   if  the 


132  MENTAL   DISEASES 

origin  of  the  word  is  to  protect  its  meaning,  a  neu- 
rosis should  limit  itself  to  a  functional  disturbance 
of  some  certain  part  of  the  nervous  system,  without 
any  mechanical  lesion  sufficient  to  be  a  full  cause. 
Taken  thus,  traumatic  neurosis  is  hardly  a  mental 
disease,  but  it  may  become  an  important  factor  in 
adding  mental  to  physical  symptoms  and  thus  be 
enmeshed  in  its  own  consequences. 

A  logger  was  struck  by  the  roll  of  a  falling  tree, 
and  suffered  a  fractured  rib  and  a  bruise  of  the  left 
shoulder.  He  had  hospital  care,  until  dismissed  as 
in  condition  for  work,  and  feeling  well  himself. 
When  he  started  to  work  the  movement  of  the  arm 
brought  pain,  so  he  stopped,  came  to  town,  and 
stayed  with  his  brother.  Some  three  weeks  later, 
when  examined,  the  story  given  was  of  a  condition 
not  progressively  worse.  Upward  movement  of  the 
arm  brought  pain,  but  with  gentle  force  the  hand 
could  be  put  on  top  of  the  head.  With  the  arms 
moved  up,  there  was  a  muscle  twitching  at  the  back 
of  the  left  shoulder.  For  the  left  side  of  the  trunk 
and  left  arm  there  was  diminished  sensibility  to  ex- 
ternal stimuli,  much  of  the  time  a  hemicrania,  the 
extended  hands  showed  a  tremor,  and  for  both  eyes 
the  field  of  vision  was  somewhat  limited.  In  the 
case  of  this  patient  it  is  believed  that  the  accident 
did  certain  actual  injury,  but  not  of  a  sort  to  be  re- 
sponsible for  all  of  the  several  sjTnptoms  recorded. 


PSYCHOGENIC    NEUROSIS  133 

Sometimes  the  Mannkopf  test  is  of  help.  Pressure 
on  a  point  alleged  to  be  painful  is  made  with  the 
pulse  under  observation;  when  there  is  actual  pain 
usually  the  reflex  action  quickens  the  rate. 

The  course  may  stretch  into  months  or  years,  but 
with  the  aggravating  conditions  removed,  the  prog- 
nosis is  good. 

3.  Dread  Neurosis  is  developed  out  of  a  psychic 
trauma  and,  displaying  some  certain  anxiety,  comes 
to  limit  and  color  everything  for  that  individual. 
Commonly  some  of  the  more  frequent  and  ordinary 
acts  are  involved.  The  beginning  may  be  connected 
with  an  illness  or  some  temporary  fault  that  sug- 
gests thoughts  of  fear,  which  through  subnormal 
judgment  may  enter  at  the  point  of  least  resistance 
and  become  established.  The  dread  may  concern 
itself  with  any  ordinary  physical  act,  or  with  the 
inability  to  do  other  things  that  belong  to  the  life 
of  the  patient,  and  this  fear  having  invaded  some 
particular  field  is  progressive  there.  Some  instances 
go  on  to  full  incapacity  and  show  extreme  suffering, 
but  it  is  characteristic  that  pain  of  some  actual 
physical  sort  is  philosophically  accepted  as  belong- 
ing to  its  cause. 

The  course  is  tedious,  but  recovery  may  come. 


CHAPTER  XVI 

COXSTITUTIOXAL  PSYCHOPATHIC  STATES: 

UNDIAGNOSED  PSYCHOSES:  INCIDENTAL 

COMMENTS 

Tlie  constitutional  psychoijcitliic  states  gives  an  ap- 
propriate name  under  which  can  be  classified  cer- 
tain individuals  of  pathologic  mentality,  who  can 
not  well  be  diagnosed  within  any  one  of  the  ordinary 
fonns  of  mental  disease,  but  who  have  a  defect  in 
character  that  has  developed  far  enough  in  some  one 
direction  to  get  a  name  for  itself;  thus,  there  is 
criminalism,  emotional  instability,  inadequate  per- 
sonality, nomadism,  paranoid  personality,  path- 
ological liar,  sexual  psychopathy,  also  other  forms. 

A  hospital  classification  properly  makes  a  place 
for  those  ''not  insane"  and  not  classified.  The  com- 
mitment examination  occasionally  is  done  under 
circumstances  of  disadvantage,  as  in  the  case  of  a 
foreigner  who  speaks  only  his  own  language  and 
does  not  have  an  interpreter;  or  where  some  condi- 
tion of  confusion  or  other  disturbance  really  belongs 
to  general  medicine.  In  such  instances  it  may  be 
advisable  that  the  patient  have  hospital  care  pend- 
ing the  development  of  the  diagnosis. 

134 


COXSTITUTIOXAL    PSYCHOPATHIC    STATES  135 

In  other  cases  there  may  be  evidence  beyond  dis- 
pute of  mental  fault,  and  yet  in  the  group  of  symp- 
toms, too  much  of  a  dei3arture  from  any  recognized 
t}T3e  to  be  well  placed  with  a  label.  This  confusion 
can  come  when  one  mental  disease  has  been  compli- 
cated by  a  second,  or  when  the  patient  is  too  atypical 
in  signs  and  sjmiptoms  to  be  put  within  the  defini- 
tion of  any  one  psychosis.  For,  while  in  the  scheme 
of  a  classification  the  dividing  lines  are  w^ell  drawn, 
in  practice  these  may  be  rubbed  out  by  borderline 
patients. 

In  the  naming  of  a  mental  disease,  the  procedure 
is  sometimes  easy,  without  dispute,  and  likely  to 
stay  without  change.  But  again,  as  noted  in  the 
chapter  on  Examination,  there  are  cases  where  con- 
tinued observation  gets  additional  facts,  special  ex- 
aminations add  technical  information,  and  the  pass- 
ing of  time  allows  comment  as  to  the  progressiveness 
of  the  condition,  and  thus  may  prove  the  wisdom 
of  a  provisional  diagnosis  open  to  revision. 

Of  the  different  mental  diseases  there  are  two 
which  stand  ajDart  as  being  nearer  to  the  normal 
than  the  others.  Epilepsy  and  the  manic  depressive 
group  have  in  common  what  is  often  a  fully  ra- 
tional interval.  Just  then  on  immediate  evidence 
such  a  loatient  could  be  judged  sane,  but  it  is  more 
reasonable  to  speak  of  recovery  from  the  attack  and 


136  MENTAL   DISEASES 

to  have  in  mind  the  liability  of  its  return.  The  fre- 
quency and  character  of  the  attacks  give  data  for 
an  opinion  as  to  the  manner  in  which  such  a  patient 
would  probably  conduct  himself  away  from  hospi- 
tal supervision. 


CHAPTER  XVII 

SHELL  SHOCK 

Shell  shock  has  not  been  formally  classed  as 
psychosis,  but  inasmuch  as  one  fifth  of  the  pres- 
ent war  disabilities  are  thus  listed,  the  subject 
claims  serious  attention. 

The  sjTuptoms  and  signs  vary.  They  are  both 
physical  and  mental.  Often  the  latter  are  the  more 
prominent. 

Usually  the  sufferer  is  befogged,  disoriented, 
and  shows  amnesia.  He  does  not  hear  orders, 
may  laugh  or  cry,  and  is  liable  toi  wander  away  with- 
out any  effort  at  keeping  out  of  danger.  Involun- 
tary movements,  twitching,  spasms,  jerks,  or  even 
convulsions  can  happen.  Cases  of  temporary  blind- 
ness or  deafness  accompanied  by  frightful  halluci- 
nations are  recorded.  Profuse  sweating  is  a  com- 
mon symptom,  and  the  shock  patient  often  starts 
from  sleep  in  terror.  Some  shoAv  xDeculiarities  of 
gait  awkwardly  dragging  heavy  feet,  carry  their 
bodies  twisted  towards  some  trench  position,  or  per- 
haps develop  monoplegia. 

The  type  and  variety  of  manifestations  has  the 
range  of  traumatic  hysteria.    It  was  observed  that 

137 


138  MEXTAL   DISEASES 

many  cases  happened  Avithout  exposure  to  any  ex^ 
ternal  violence,  and  this  led  to  the  belief  that  a 
large  part  of  the  whole  group  were  iDroperly  in- 
stances of  a  psychoneurosis ;  a  functional  distur- 
bance without  any  definite  pathological  background. 

Doctor  M.  Allen  Starr  in  a  brief  article*  skill- 
fully reviews  the  most  recent  studies  that  have  to 
do  with  the  evidence  of  physiological  and  patholog- 
ical changes  found  in  shell  shock. 

The  soldier  is  taken  rather  abruptly  from  his 
home,  carried  through  a  tim^e  of  intensive  training, 
put  in  the  battle  area  where  first  he  sees  the  wound- 
ed and  hears  stories  of  atrocities,  and  then  is  him- 
self in  the  front  trenches  waiting.  The  alertness 
and  tension  demanded  produce  as  secretions  the 
body  substances  needed  to  supply  the  muscles  nour- 
ishment for  strenuous  activity.  A¥hen  opportunity 
of  relief  in  action  is  denied,  these  same  substances 
reabsorbed  become  toxic. 

Babbits  kept  aAvake  one  hundred  hours  die,  and 
the  brain  cells  show  depletion.  The  same  findings 
are  made  when  a  rat  is  frightened  to  death.  This 
is  the  change  of  exliaustion,  and  it  is  believed  that 
men  may  suffer  from  similar  cause. 

Further,  autopsies  in  shell  shock  cases  have  found 
multiple  scattered  minute  hemorrhages  (sometimes 
hundreds)  which  explain  disconnected  s^^njotoms. 


*See   Scribner's   Magazine,    August,    191S. 


SHELL    SHOCK  139 

Atmospheric  loressure  in  the  vicinity  of  a  large 
shell  becomes  ten  tons  to  the  square  yard,  then 
yields  to  a  corresponding  depression.  Such  an 
ahrui^t  change  in  atmospheric  pressure  can  produce 
bubbles  of  gas  in  the  blood  which  do  damage  as  em- 
boli. 

These  are  given  as  some  of  the  explanations  for 
shell  shock. 

It  is  probable  that  a  strict  psychoneurological  ex- 
amination made  by  the  draft  boards  could  have 
done  much  to  protect  the  army  in  its  record,  for 
connnonly  the  essential  ground  work  lies  in  the  in- 
dividual himself,  and  the  weakest  always  breaks 
first.  However,  in  many  instances  the  causes  re- 
ferred to  give  full  organic  evidence  for  the  develop- 
ment of  all  the  findings  gotten  in  shell  shock. 


INDEX 


Alcoholic  i>sychosis,  111 
Apoplexy,  90 

Argyll  Eobertson  reaction,  59 
Arteriosclerotic  psychosis,  86 
Ataxia,  23 


G 

General  paralysis,  57 

H 

Hallucination,  23 
Huntington's  chorea,  79 
Hysterical  insanity,  130 


Babinski's  sign,  81 
Brain  abscess,  89 
Brain  tumor,  88 


Cerebral  syphilis,  82 
Cerebral  trauma,  90 
Cocainism,  120 

Constitutional   inferiority,    105 
Constitutional    psychopathic 

states,  134 
Cretinism,   122 
Criminalism,  134 

D 

Delusion,  23 
Dementia  precox,  40 
Dread  neurosis,  133 

E 

Emotional  instability,  134 
Epileptic  psychoses,  74 
Examination,  25 
Exhaustion  psychoses,  127 


Illusion,  24 

Imbecile,  107 

Inadequate   personality,   134 

Infection  psychoses,  125 

Insanity,  22 

Involution  melancholia,  96 

Involution  psychoses,  96 

K 

Katatonia,  47 

Korsakow  's  psychosis,  114 

M 

Manie  depressive  psychoses,  30 

Melancholia,  96 

Mental  deficiency,  105 

Morphinism,  118 

Moron,  107 

Multiple  sclerosis,  80 

Myxedema,  121 


N" 


Nomadism,   134 


141 


142 


IlfDEX 


Orientation,   24 


Paranoia,   66 

Paranoid  personality,  134 
Pathologic  liar,  134 
Presenile  delusional  insanity, 

100 
Pressure  of  activity,  24 
Psyeliogenic  neurosis,  130 
Psychomotor  activity,  24 
Psvchosis,  24 


S 

Senile  dementia,  100 

Senile  psychoses,  96 

SheU  shock,  137 

Spinal  fluid  examination,  64 


Tabetic  j)sychosis,  84 
Thyrdigeuous   psychoses,    121 
Traumatic  neurosis.  131 
Traumatic  psychoses,  90 


COLUMBIA   UNIVERSITY 


This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

&JFR     1    i       \^l 

4 

C2e'638)MS0 

